Inspection·November 2, 2023

F 0684 included treatment as per order and monitor for s/sx of infection. Level of Harm - Minimal harm or potential for actual harm - had a pressure area to location: Sacrum Stage III. Interventions included perform treatment per order. -had Left Inner Ankle Wound x 2 (vascular) and open area to sacrum. Interventions Residents Affected - Some included to provide treatment per physician order. - had Wound to Left Lateral Leg (vascular). Interventions included follow facility protocols for treatment of injury. - had potential for impairment to skin integrity r/t decreased mobility. Interventions included observe and identify any new affected skin area, intervene with treatment as necessary and notify MD. - had an arterial ulcer of the left outer foot. Interventions included monitor/document wound, monitor/document/report PRN any s/sx of infection, and weekly treatment documentation. - had an arterial/ischemic ulcer of the left outer ankle. Interventions included monitor/document wound, monitor/document/report PRN any s/sx of infection, and weekly treatment documentation. Record review of Resident #1's annual MDS assessment, dated 08/08/23, revealed Section C, Cognitive Patterns, C0100, BIMS was unable to be conducted as resident was rarely/never understood. Further review revealed she required one-person physical assist with bed mobility and toileting, and two-person physical assist with transferring. Section M, Skin Conditions, M0150. Risk of Pressure Ulcers/Injuries revealed she was at risk of developing pressure ulcers/injuries. Record review of Resident #1's treatment orders, dated August 2023, included: -Left ankle (inner area) wound, clean with NS, pat dry, apply Santyl and Bactroban cover with dry dressing QD. every day shift for wound care, start date 08/08/23 and discontinued date 08/23/23. -Left foot (inner area) wound, clean with NS, pat dry, apply Santyl and Bactroban and cover with dry dressing QD. every day shift for wound care, start date 08/08/23 and discontinued date 08/23/23. Record Review of Resident #1's TAR dated for August of 2023, revealed wound care treatment on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 2 of 11 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 11/02/2023 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 08/18/23 and 08/19/23 was blank. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's treatment orders, dated September 2023, included: Residents Affected - Some - Left ankle (inner area) Arterial wound, clean with NS, pat dry, apply Alginate cover with dry dressing QD. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date of 08/24/23. -Left foot (inner area) Arterial wound, clean with NS, pat dry, apply Alginate and cover with dry dressing QD. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 08/24/23 to 09/13/23. -Left foot (inner area) Arterial wound, clean with NS, pat dry, apply Skin Prep and LOTA. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 09/14/23. -Stage 2 Coccyx: cleanse with wound cleanser pat dry, apply ca alginate, cover with dry dressing once a shift and PRN. Report any changes to Wound Dr and TX Nurse. every day shift for wound care, start date of 09/05/23 to 09/07/23. - Stage 3 Sacrum: cleanse with wound cleanser pat dry, apply ca alginate and Santyl, cover with dry dressing once a shift and PRN Report any changes to Wound Dr. and TX Nurse. every day shift for wound care, start date 09/14/23. -Stage 3 Sacrum: cleanse with wound cleanser pat dry, apply ca alginate, cover with dry dressing once a shift and PRN. Report any changes to Wound Dr. and TX Nurse. every day shift for wound care, start date 09/08/23 to 09/13/23. -Stage 2 Sacrum: Cleanse with NS, pat dry, apply zinc and LOTA every shift and PRN. Report any changes to Wound Dr and TX Nurse. every shift for Wound Treatment, start date of 08/23/23 to 09/05/23. Record Review of Resident #1's TAR dated for September of 2023, revealed wound care treatment on 09/02/23, 09/07/23, 09/10/23, 09/16/23, 09/17/23, 09/25/23, 09/26/23, 09/27/23, 09/28/23 was blank. Record review of Resident #1's treatment orders, dated October 2023, included: -Left ankle (inner area) Arterial wound, clean with NS, pat dry, apply Alginate cover with dry dressing QD. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 08/24/23. -Left foot (inner area) Arterial wound, clean with NS, pat dry, apply Skin Prep and LOTA. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 09/14/23. -Stage 3 Sacrum: cleanse with wound cleanser pat dry, apply ca alginate and Santyl, cover with dry dressing once a shift and PRN. Report any changes to Wound Care Dr and TX Nurse. every day shift for wound care, start date 09/14/23. - Wound Treatment to Left ankle (outer area) Arterial wound Remove old dressing, cleanse with wound cleanser, apply skin prep and LOTA. every day shift for Wound Care, start date 10/12/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 3 of 11 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 11/02/2023 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 - Minimal harm or potential for actual harm - Wound Treatment to left big toe: cleanse with wound cleanser, apply CA, Honey, and LOTA every day shift for Wound Care, start date 10/12/23. -Wound Treatment to left medial toe. Cleanse with wound cleanser, apply skin prep and LOTA every day shift for Wound Care, start date 10/12/23. Residents Affected - Some Record Review of Resident #1's TAR dated for October of 2023, revealed wound care treatment on 10/01/23 and 10/14/23 was blank. Record review of Resident #1's wound care assessments completed by the Wound Care Physician, dated 08/07/2023 and 10/18/23, revealed the following: -Left, medial malleolus wound improved from 2.7x2.5x0.5 to 0.9x1.4x0.1 -Left, medial midfoot wound improved from 1.3x1.2x0.2 to 0.9x0.9 -Sacrum wound improved from 6.5x3.9x0.1 to 3.9x2.9x0.1 -Left, medial forefoot improved 1.6x1.4 to 1.5x1.2x1 -Left, medial first toe improved 1.6x1.4 to 0.5x0.7 Resident #2 Record review of Resident #2's admission Record, dated 10/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident's diagnoses included sepsis (infection of the blood stream), type 2 diabetes (high blood sugar) without complications, and pressure ulcer of sacral (below lumbar spine and above tailbone) region, stage 4. Record review of Resident #2's care plan, undated, revealed the following: - at risk for impairment to skin integrity r/t hx of pressure ulcers. Interventions included observe and identify any new affected skin area, intervene with treatment as necessary and notify MD. - pressure ulcer(s) stage 4 to sacrum. Interventions included administer treatments as ordered and monitor for effectiveness. Record review of Resident #2's admission MDS assessment, dated 10/06/23, revealed a BIMS score of 9, indicating moderately impaired cognitive skills. Further review revealed resident required 2-person assistance with toileting, bathing, and dressing. Section M, Skin Conditions, M0150. Risk of Pressure Ulcers/Injuries revealed he was at risk of developing pressure ulcers/injuries. Record review of Resident #2's treatment orders, dated October 2023, included the following: -Stage 4 pressure wound (Sacrum): Cleanse with ns/wc, pat dry, apply Calcium Alginate and cover with dry dressing daily and PRN soiled every day shift for pressure wound, start date 10/01/23 and discontinued date 10/11/23. Record Review of Resident #2's TAR, dated for October of 2023, revealed Resident #2's wound care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 4 of 11 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 11/02/2023 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 treatment on 10/01/23 was left blank. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's wound care assessments completed by the Wound Care Physician, dated 10/04/23 and 10/18/23, revealed sacrum wound had improved from 10.9x14.6x3.9 to 9.9x13x3.3. Residents Affected - Some Resident # 3 Record review of Resident #3's admission Record, dated 10/17/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease with late onset, hypertensive heart disease (high blood pressure) with heart failure, pressure ulcer of sacral (below lumbar spine and above tailbone) region, unstageable, and cellulitis (bacterial infection of the skin) of left lower limb. Record review of Resident #3's care plan, undated, revealed the following: - had a pressure area to location: Sacral, 7/29/2023-Unstageable wound to Sacrum. Interventions included perform treatment per order. - had an arterial ulcer of the 4th toe left foot. Interventions included monitor/document wound, monitor/document/report PRN any s/sx of infection, and weekly treatment documentation. Record review of Resident #3's quarterly MDS assessment, dated 09/29/23, revealed the BIMS was unable to be conducted due to resident rarely/never being understood. Further review revealed resident required two-person physical assist with mobility, transferring, and toileting. Section M, Skin Conditions, M0150. Risk of Pressure Ulcers/Injuries revealed she was at risk of developing pressure ulcers/injuries. Record review of Resident #3's treatment orders, dated August 2023, included: - Left 2nd Toe (Trauma wound): Cleanse with normal saline/wound cleanser, pat dry, apply Bactroban and LOTA every day shift, start date 08/09/23 to 08/23/23. - Sacrum (Stage 3): Cleanse with normal saline/wound cleanser, pat dry, apply CA-Alginate and cover with dry absorptive dressing daily. Report any changes to Wound Dr. and TX Nurse every day shift for Wound Treatment, start date 08/25/23 to 08/29/23. - Sacrum (Unstageable pressure injury): Cleanse with normal saline/wound cleanser, pat dry, apply Santyl, apply Alginate and cover with dry absorptive dressing daily every day shift for pressure wound, start date 08/09/23 to 08/24/23. - Wound Treatment- (Arterial) 4th toe on right foot: cleanse with NS or Wound Cleanser, pat dry, apply Alginate to area, and cover with dry dressing. Report any changes to Wound Dr and TX Nurse every day shift for Wound Treatment, start date 08/25/23 to 10/02/23. -Wound Treatment to coccyx area: remove old dressing, cleanse with Vashe, pat dry, apply collagen Santyl & Ca Alginate to wound bed, and cover with bordered gauze dressing every 24 hours for wound, start date 08/01/23 to 08/09/23. -Wound Treatment to left second toe: clean with betadine. Leave open to air. Monitor swelling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 5 of 11 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 11/02/2023 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 every 24 hours, start date 08/01/23 to 08/09/23. Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #3's TAR dated for August of 2023, revealed Resident #3's wound care treatment on 08/01/23, 08/11/23, 08/24/23, 08/26/23, and 08/27/23 was blank. Residents Affected - Some Record review of Resident #3's treatment orders, dated September 2023, included: -Sacrum (Stage 3): Cleanse with normal saline/wound cleanser, pat dry, apply CA-Alginate and cover with absorptive dressing foam daily. Report any changes to Wound Dr. and TX Nurse every day shift for Wound Treatment, start date 08/30/23. -Wound Treatment- (Arterial) 4th toe on right foot: cleanse with NS or Wound Cleanser, pat dry, apply Alginate to area, and cover with dry dressing. Report any changes to Wound Dr and TX Nurse every day shift for Wound Treatment, start date 08/25/23 to 10/02/23. Record Review of Resident #3's TAR dated for September of 2023, revealed wound care treatment on 9/2/23, 9/10/23, 9/16/23, 9/17/23, 9/24/23, 9/26/23, 9/27/23, 9/28/23 was blank. Record review of Resident #3's treatment orders, dated October 2023, included: -Sacrum (Stage 3): Cleanse with normal saline/wound cleanser, pat dry, apply CA-Alginate and cover with absorptive dressing foam daily. Report any changes to Wound Dr. and TX Nurse every day shift for Wound Treatment, start date 08/30/23. -Wound Treatment- (Arterial) 4th toe on right foot: cleanse with NS or Wound Cleanser, pat dry, apply Alginate to area, and cover with dry dressing. Report any changes to Wound Dr and TX Nurse every day shift for Wound Treatment, start date 08/25/23 to 10/02/23. Record Review of Resident #3's TAR dated for October of 2023, revealed wound care treatment on 10/01/23, 10/02/23, and 10/14/23 was blank. Record review of Resident #3's wound care assessments completed by the Wound Care Physician, dated 10/18/23 and 08/07/23, revealed sacrum wound improved from 3.0x1x0.5 to 2.2x0.7x0.2. Resident #4 Record review of Resident #4's admission Record, dated 10/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included sepsis (infection of the blood stream), type 2 diabetes mellitus (high blood sugar) without complications, unspecified open wound of penis, and pressure ulcer of unspecified site, unspecified stage. Record review of Resident #4's care plan, undated, revealed the following: - had potential for actual impairment to skin integrity r/t decreased mobility. Interventions included observe and identify any new affected skin area, intervene with treatment as necessary and notify MD. Record review of Resident #4's admission MDS assessment, dated 09/25/23, revealed a BIMS score of 14, indicating intact cognitive skills. Further review revealed resident was a two-person assist with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 6 of 11 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 11/02/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some mobility, transferring, and toileting. Section M, Skin Conditions, M0150. Risk of Pressure Ulcers/Injuries revealed he was at risk of developing pressure ulcers/injuries. Record review of Resident #4's treatment orders, dated October 2023, included the following: -Cleanse sacral ulcer with normal saline, pat dry, cover with protective dressing every day shift for sacral ulcer, start date 09/21/23. -Cleanse tip of penis with normal saline, pat dry, apply xeroform, cover with abd pad for gangrene every day shift for gangrene, start date 09/21/23. Record Review of Resident #4's TAR, dated for October of 2023, revealed wound care treatment on 10/01/23 and 10/15/23 was blank. Record review of Resident #4's wound care assessments completed by the Wound Care Physician, dated 10/04/23 and 11/01/23, revealed coccyx wound improved from 4.0x2.9x1.2 to 3.2x1.6x1.0 and his penis wound remained the same at 12.6x7.9x0.2. In an interview on 10/18/23 at 11:51 a.m., Nurse B said she had been working at the facility for 3 ½ months. She said she worked on Station 1 which covered halls 100, 200, and 300. She said she only did wound care once since she started working at the facility. She said she did the wound care for her residents on her hall because they just got a new wound care nurse who was in training. She said she did not know the exact time, but it was within the past three weeks that the wound care nurse started working at the facility. She said it was prior to the new wound care nurse being employed. She said she heard the new DON was the wound care nurse then and had just been promoted to DON. She said the weekend supervisor (she was not sure of the name of the supervisor) also did wound care on weekends. She said if the wound care nurse was not in the building, she did not know who was responsible for doing wound care and said no one ever told her who would be responsible if the wound care nurse not there. She said, they always have wound care nurse. She said she never encountered a situation when the wound care nurse was not at the facility. She said she got three days of training on general stuff - on the care to be provided to residents but did not have any competency checks - like when she did wound care, and someone watched her. She said she was a new graduate nurse, and she still remembered all her stuff and she would watch videos. She said staff were a great support - her fellow workers and the DON. She said she never heard any complaints from the residents about their wounds. She said she never saw any outdated wound dressings. In an interview on 10/18/2023 at 12:10 p.m., Agency Nurse A said she worked the day shift on 09/10/23. She said she did wound care for a couple of the residents but did not quite remember. She said she did not remember documenting them. She said she did not really remember everything from that day. She said she knew that it was her and a nurse on the other side and a nurse in the locked unit. She said she did not think there was a wound care nurse at that time. She said she did not remember having a conversation with anyone about who would be responsible to do wound care if the wound care nurse was not in the building. She said that day was like the first time I ever been to that place and no resident complained to her about their wound. Observation on 10/18/2023 at 1:55 p.m., wound care with the DON for Resident #3- revealed sacrum wound stage 2 had a dressing dated 10/17/23. Surveyor observed for technique and infection control during the wound care and there were no concerns at the time of the observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 7 of 11 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 11/02/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 10/18/2023 at 3:44 p.m., the Wound Care Nurse said she was hired on 10/10/23 and started working on the floor on 10/12/23. She said she was still in training. She said today was the first day she completed rounds with the wound care doctor who came to the facility every Wednesday. In an interview on 10/19/2023 at 9:10 a.m., Nurse A said she had been working at the facility since June 2023. She said she completed wound care on various days but most of the time during the week and not as much during the weekends. She said wound care was always completed during the first shift, 6:00 a.m. to 6:00 p.m. She said the last time she performed wound care was last Saturday, 10/14/23, for halls 500 and 600. She said there was not a wound care nurse working that day. She said approximately 3 weeks ago, 09/27/23, she was the designated wound care nurse for the entire building, and said she was able to complete wound care on all the residents. She said she also probably performed her own wound care for her assigned residents on 09/02, 09/16, and 09/17. She said on October 15th they had a wound care nurse. She said every time she completed wound care, she went into the computer system and documented it was completed on the TAR. She said she would not document completion of treatment anywhere else unless there was something unusual i.e., change in the wound, in which case she would write a progress note. She said she was bad at remembering to chart the completion of wound care treatments on the TAR. She said the purpose of the TAR was to chart treatments and the instructions for the wound treatment orders. She said if the treatment was not charted then it was not done. She said the potential effect on residents if their wound care was not completed was wound deterioration. In a telephone interview on 10/19/23 at 12:22 p.m. Agency Nurse B said she had been picking up shifts at the facility for over a year and did not do wound care as a floor nurse but said she did do wound care on 10/10/23 when she was working as the treatment nurse. She said she documented all of her treatments on 10/10/23. She said she last worked at the facility on 10/10/23 and worked the 9:00 a.m. to 5:00 p.m. shift. She said she also worked on 09/28/23. She said she worked halls 500 and 600 on 09/28/23 and on 10/10/23. She said on 09/28/23 she did not have to complete wound care because there was a wound care nurse, but she did not remember their name. She said they would specify on the agency app, or the agency would tell them if they needed to perform wound care on the shift they picked up. She said she did not follow-up with the residents to see if they received their wound care treatments on 09/28/23 because she was certain the wound care nurse was there. In an interview on 10/19/23 at 1:31 p.m., the DON said she had been the facility's DON since 10/02/23. She said prior to the new hire of the wound care nurse, she was the treatment nurse from 08/01/23 to 10/01/23. She said the purpose of the TAR was to follow the treatment that was on there and to sign off on it once it had been completed. She said she worked 6:00 a.m. to 6:00 p.m., Mondays-Thursdays, and on Fridays she would only do wounds and would then go home. She said if she was out of the building the nurses on the floor were responsible for providing wound care to their assigned residents. She said on the weekends they used to have a weekend supervisor. She said as soon as the weekend supervisor quit, she made a sign that said nurses were to do their wounds on the weekends they worked. She said the nurses were told verbally, and a sign was posted at the nurse's station. She said agency staff were notified via the same method and that they were responsible for doing their own wound care. She said agency staff were already supposed to be trained on performing wounds and should be advanced in that they go from facility to facility conducting wound care. She said the only documentation they do was on the TAR. She said the TAR was the documentation that showed wound care was completed. In a follow-up interview on 10/19/23 at 2:04 p.m., the DON said she was not scheduled to work on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 8 of 11 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 11/02/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some 08/11/23. She said she was out with COVID-19 from 09/24/2023 to 10/01/2023. She stated sometimes when she got pulled from the treatment or if any nurse called out sick, she would work the floor and every nurse would be responsible to do their own wound care for the residents on the floor. In a follow-up interview on 11/01/23 at 12:30 p.m., the DON said the wound care doctor came to the facility every Wednesday. She said there was one day in September, when he texted her on 09/27/2023 at 7:17 a.m., and said he would not be going to the facility because he had a procedure. She said she completed wound care reports every time he saw a resident, he left the reports with the facility, and asked them if they had any questions. She said he would let them know if there were any changes to a resident's orders or if they were staying the same. She said every time he was at the facility, a nurse rounded with him, he would let the nurse know if the wound had gotten better or worse, if the resident needed an air mattress, if they need a vascular order, or anything he thought was needed based on his observation. She said the wound care nurse was no longer working at the facility. She said the last day she worked was on October 24, 23. She said she currently did the Wound Care rounds with the wound care doctor on Wednesdays, and after he was done, she would update the wound care report and orders on that same day. She said during the week, the nurses were doing their own wound care treatments for their assigned halls. She said the facility had a Weekend Supervisor who did wound care treatments for all the residents on the weekends. In a telephone interview on 11/01/23 at 2:16 p.m., Agency Nurse C said she was not sure when she last worked at the facility but believed it was 2 to 3 weeks ago. She said she was not 100% sure but believed she performed a few wound care treatments on 10/01/23. She said she did not follow-up with anyone that day to see if the residents got their wound care treatments. She said the facility did not tell her who was responsible for doing wound care if the wound care nurse was not in the building. She said she honestly did not remember and was not asked anything by facility staff. She said she also worked on 10/07/23 and helped the wound care nurse complete wound care treatments but did not remember the nurse's name. She said if a resident had an order for wound care, she followed the order, and would check it off on the order after it was completed. She said there was not a sign posted at the nurse's station that said if there was not a wound care nurse in the building, the nurses were responsible for doing their own wound care. In an interview on 11/01/2023 at 2:52 p.m., Agency Nurse D said there was only one day, and he was not too sure what day, but believed it was 10/01/2023, that he was initially listed on the schedule to be the wound care nurse. He said he was reassigned that day to be a floor nurse because one of the nurses did not show up. He said as far as he could recall, he never performed wound care for the facility but was not too positive. He said he did not know who was assigned to do wound care on 10/01/23. He said he did not recollect the facility ever telling him that he had to do wound care for his assigned residents if there was not a wound care nurse on shift. He said he did not check with the residents to see if wound care was completed because sometimes, they were not able to verbalize. He said he was not sure if the facility had a wound care nurse on 10/01/23. He said he did not recall ever seeing a posted sign at the nurses' station stating if there was not a wound care nurse, the floor nurse was responsible for doing their own wound care. He said he did not know if there was a weekend supervisor at the facility on 10/01/23. He said if he had to do wound care, he wound go into the computer system, would look at the orders, and would document on the TAR that it was completed. In a follow-up interview on 11/02/2023, Nurse A said she always worked the day shift, 6:00 a.m. to 6:00 p.m. She said sometimes her duties included wound care. She said the DON would let them know when they had to do wound care which happened once in a while. She said the blanks on the TAR did not necessarily mean wound care was not done. She said it could have been done or somebody did it and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 9 of 11 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 11/02/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some did not chart. She said in nursing, if it was not charted, it was not done. She said charting was on a different screen, so if you did not go to that screen, it would not get charted. She said it used to happen often, but not anymore. She said it really did not happen often that it was not done or not charted. She said on 10/30/23 she came to work late and worked half a day. She said when she came in on the 30th, no one told her to do wound care. She said she was probably supposed to do wound care that day but did not. She said she did not know she was supposed to do it that day. She said the night shift nurse or day shift could do it. She said sometimes wound care was done on the night shift. She said they communicated during clinical hand off, that wounds did not get done. She said on 10/30/23 she did not tell the night shift that wounds did not get done. She said possibly the DON or ADON may have known about Resident #1 missing treatment that day. She said she had a few in-services on wound care in the last 4 months. She said if wound care was not done, skin breakdown or infection could happen. An attempted telephone interview on 11/02/2023 at 12:28 p.m., with the Wound Care Doctor was made. A voicemail was left requesting a return call. In an interview on 11/02/23 at 1:15 p.m., the Weekend Supervisor said she started working at the facility on 10/15/23. She said she worked weekends from 7:00 a.m. to 7:00 p.m. She said some of her job responsibilities included completing wound care. She said she believed they had a treatment nurse during the weekdays. She said once she completed wound care, she would document it on the TAR. She said if she was not able to work her shift, she would notify the DON. She said she trained with the DON on 10/15/23 and the following weekend with Nurse C. She said if the completion of wound care was not documented on the TAR, it meant it was not done. She said she would have to check her records to see if she did wound care on 10/15/23. She said in order to answer what could happen it a resident did not to get their wound care treatment she would also have to check her records. In a telephone interview on 11/02/23 at 1:48 p.m., Nurse C said she had been working for the facility since May 2021 and worked during the week and weekends. She said she worked 6:00 p.m. to 6:00 a.m. on Thursday, 10/26/23. She said she did not remember if she had to do wound care that day. She said if a resident's dressing came off, she would redo the wound care. She said she remembered having to do a redressing for Resident #2 on 10/26/23. She said she did not have to do wound care because the facility had a wound care nurse. She said she had not seen any outdated dressings as far as she could remember. She said on Thursday, 10/26/23, she completed wound care for resident in room [ROOM NUMBER]. She said she did not remember who was responsible for wound care on 10/26/23. She said she thought the nurse did wound care for Resident #4 that day. She said the DON told her that if the wound care nurse was not in the building, the nurses were responsible for completing their wound care. She said once wound care was completed, it was checked off on the TAR. She said if it was not checked off on the TAR, it meant it was not done. She said if wound care treatment was not completed, sepsis and/or an infection could set in. In an interview on 11/02/23 at 2:08 p.m., Agency Nurse E said there was never a wound care nurse when she worked. She said she worked on the weekends and usually worked the day shift from 6:00 a.m. to 6:00 p.m. She said the last time she worked was in September 2023. She said she received a notification from the agency that she did not complete all of the residents' wound care treatments. She said she did not know there was a different screen that she had to go into to see who needed wound care treatments. She said she had no idea about the treatment tab in their computer system. She said throughout providing care for the residents, she noticed residents that had wounds and questioned the nurse. She said the nurse showed her where to look in the computer system. She said she never noticed any outdated dressings. She said when she logged on for her shift it would tell her if she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 10 of 11 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 11/02/2023 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 - Minimal harm or potential for actual harm Residents Affected - Some residents that had wounds. She said she never received training from the facility on their computer system. She said she completed whatever she could see in the system. She said if there was not a wound care nurse in the building, she was never told who was responsible for completing wound care. She said once wound care was completed, she would check it off on the TAR. She said it was very possible she missed doing wound care treatments in August 2023. She said if wound care was not checked off on the TAR, it ultimately meant it was not done and/or someone forgot to check it off. In a follow-up interview on 11/02/23 at 2:49 p.m., the DON said there had been no negative outcomes with Residents #3 and #4. She said Resident #4's sacrum wound was improving, and his penis wound was not going to improve because those wounds just did not normally heal as told by the wound care doctor. She said this was disc FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 11 of 11