Inspection·October 7, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Relaxed and regular. Rhythm regular 18 resp per min lung sounds clear throughout. Resident sitting in bed with HOB 45 degrees. No distress noted.- On 10/06/25 at 11:45 PM, Chest X-Ray 2 views results: No evidence of acute cardiopulmonary disease. Stable when compared to prior exam. Result send to NP for review. No new orders. Responsible party at bedside and was notified. Record review of Resident #1's Radiology Results Report dated 10/06/25 at 6:20 PM revealed, PROCEDURE: Chest Xray; INDICATION: Pneumonia; IMPRESSION: No evidence of acute cardiopulmonary (relating to the heart and the lungs) disease. An observation on 09/29/25 at 11:34 AM revealed Resident #1 lying in bed receiving formula via G-tube. The resident was non-responsive to this surveyor but appeared to be in no immediate distress. His breathing appeared unlabored, and he did not have a cough. An observation on 10/06/25 at 1:13 PM revealed Resident #1 lying in bed receiving formula via G-tube. The resident was non-responsive to the surveyor but appeared to be in no immediate distress. His breathing appeared unlabored, and he did not have a cough. In an interview on 10/06/25 at 1:18 PM, RN B said when a physician gave an order for an x-ray it must be documented in the 24- hour report. RN B said she was Resident #1's nurse, she had not observed him with a cough, she did not know there was a pending X-ray, she didn't know any orders were entered for Resident #1's CXR (chest x-ray). RN B said there has been no communication to her, nursing, or the RP about the pending CXR. In an interview of 10/06/25 at 1:20 PM, the DON said when radiology orders were entered by a provider, nursing staff must then confirm the order. She said she didn't know why Resident #1's X-ray had not been taken yet, Resident #1's cough that required a CXR for further evaluation was considered a change in condition so all the notifications that should be sent out. The DON said RN B confirmed the order for Resident #1's CXR in the EMR system. In an interview on 10/06/25 at 3:42 PM, MD A said when she assessed Resident #1 on 10/01/25 he was observed to have diminished lung sounds and a cough. The resident had been in and out of the hospital with pneumonia and received enteral feeds via a G-tube which put him at risk for aspiration pneumonia (pneumonia as a result of inhaling vomit) so she was concerned about the cough. She said older individuals like Resident #1 present differently from young, healthy people because their weak immune system can result in normal WBC (elevation indicative of infection), no fever, and since they can't mount the same immune response, they end up with Walking Pneumonia. MD A said in individuals like Resident #1 she would order an X-ray to rule out pneumonia. She said normally when she entered CXR orders, it took the radiology company a day perform the imaging, and the facility would then call her to notify her of the results. MD A said she was not aware the facility had not completed the CXR order she entered on 10/01/25, a 5-day delay was not acceptable and the facility shouldn't drop the ball on things like this. She would not identify any risks associated with failure to implement radiology orders timely but said it would delay identification of an issue or fail to rule out a suspected concern. In an interview on 10/06/25 at 6:04 PM, RP #2 said he did not receive notification from the facility regarding Resident #1's change of condition (cough), or the ordered CXR, and he last saw Resident #1 on 10/02/25. RP #2 said Resident #1 and was fully disabled and paralyzed on one side, and sometimes he received notifications from the facility regarding Resident #1 but this time he had not received notification of the cough or ordered CXR. Record review of Resident #24's Face Sheet dated 10/02/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: left sided paralysis after a stroke, insomnia (difficulty sleeping), depression, anxiety, stomach bleed, repeated falls and lung cancer. An implanted port was not documented in her diagnosis. Record review of Resident #24's Quarterly MDS dated [DATE] revealed severely impaired cognition as indicated by a BIMS score of 3 out of 15, upper and lower body functional limitations in range of motion, maximal assistance with most ADLs and maximum assistance with the use of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 2 of 46 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 10/07/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few manual wheelchair. Active Diagnoses of: Cancer, hypertension, high cholesterol, one sided paralysis, anxiety and depression. Record review of Resident #24's undated Care Plan revealed, Focus: potential for skin tears of the r/t limited mobility. Focus: The resident is on pain medication therapy -ACETAMENIPHEN-CODEINE, LIDOCAINE; Interventions: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness. Focus: chronic pain on lidocaine,acetaminophen codeine; Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Focus: enhanced barrier precautions r/t indwelling medical device; Interventions: ENHANCED BARRIER PRECAUTIONS is necessary during high-contact care: Dressing; Bathing; Transferring; Providing hygiene; Changing linens, changing briefs or assisting with toileting; Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes; Wound care: any skin opening requiring a dressing. Resident #24's care plan did not specify if the indwelling medical device was a port. Record review of Resident #24's Physician Order dated 07/23/25 revealed needs oncology follow up related to port removal to right chest. Record review of Resident #24's Physician Order dated 09/19/25 revealed a follow up with oncologist for port removal. Record review of Resident #24's Progress Notes from 05/20/25 to 10/07/25 reflected the following;- there was no documentation of communication to Resident #24's RP from admission to 09/17/25 in regard to the implanted port, its use, maintenance, adverse reactions or removal.- On 09/19/2025 12:40 PM signed by the DON, While auditing the chart noticed and order from 7/23/25 from MD A requesting for the resident, to follow up with Oncology for port removal. After speaking with the nurse, it was told that the family did not want the port removed. Spoke with NP A to discuss the order and if she still wanted to follow up. NP A said yes, because every time she speaks to [Resident #24]she complains of pain to the port site. Called the RP and educated him on the port and what the NP said about his mother experiencing pain related to the port. The RP son said if Resident #24 wants the port out, then we need to take it out. Educated Resident #24 on what the son said. The RP was not able to give me information about who the Oncologist was. Called the caregiver who was able to give the writer the information. The caregiver said, they did not want the port removed because they thought Resident #24 was still going to get cancer treatments. Explained to the caregiver what the [RP #2] said and the caregiver was in agreement. The caregiver gave the writer for the follow-up appointment. Writer was able to obtain an appointment for October 7, 2025. An observation and interview on 09/29/25 at 11:07 AM revealed Resident #24 lying in bed in no immediate distress. She said she was all right, but her chest was bothering her. She said it hurt to turn her arm because the tube in her (implanted port) caused her discomfort and she wanted it removed. Resident #24 said she wanted a walker because her implanted port hurt when she used a wheelchair. An observation and interview on 10/02/25 at 12:40 PM revealed Resident #24 appeared well dressed, well-groomed and in no immediate distress sitting in a wheelchair in her room. Resident #24 said her port was giving her hell, and it hurt whenever she wheeled herself in her wheelchair and the port goes (moves) up and down. She didn't say her port hurt when she was not using her wheelchair, but it let her know it is there. Resident #24 said Acetaminophen controlled her pain and the facility was working with the doctor to get her port taken out. Her implanted port was observed as circular raised area on her right chest, with loss of pigment. Her skin was intact with no redness, swelling or drainage observed. In an interview on 10/06/25 at 10:10 AM, the DON said she did not know what happened between the order received in July and September when she found the missed order. She said she didn't see any action/notifications following the physician's orders and failure to follow physician orders to assess a port with no care, could place residents at risk of infection. In an interview on 10/06/25 at 10:29 AM, RP #1 said prior to September 2025 the facility had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 3 of 46 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 10/07/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete notified him of the discomfort Resident #24 experienced due to her port. He said he had no issues with the port being removed and it was up to [Resident #24] and he provided the facility the information of her oncologist. In an interview on 10/06/25 at 10:39 AM, Resident #24's family member said September 2025 was the first time the facility notified any of the resident's family that her physician recommended removal of her port and that it caused her discomfort. In an interview on 10/06/25 at 11:09 AM NP A said the facility scheduled an appointment in September with Resident #24's Oncologist to evaluate removal of the resident's implanted port since she was no longer using it for chemotherapy. NP A said prior to September Resident #24 had an infection on her foot so she could not undergo surgery to remove the port, but she did not have any concerns for the port because it was an implanted device and the facility was not accessing it. NP A said evaluation of Resident #24's port site and labs indicated no signs and symptoms of infection. She said the facility did not have the ability to remove the port and required an Oncologist to evaluate. In an interview of 10/06/25 at 2:47 PM, the DON said when staff received a physician's order for radiology, they must enter it into the EMR which was integrated with the laboratory and then document it in the progress note and in-house 24-hour report log. She said RN B failed to document the order and follow up with the x-ray and that was why they were missed. The DON said there was no evidence of family notification of Resident #1's cough or the order for a CXR. The DON said failure to timely complete radiology orders could place residents at risk for worsening of condition and delay in care. She said Resident #1's cough and subsequent order for CXR was a change of condition and all changes of condition required notification of the doctor, notification of the family and the nursing staff to follow up on all orders and changes. The DON said failure to notify a resident's RP of changes could leave the family unaware of a resident's change of condition. Record review of the facility policy titled Notification of Changes with no date revealed, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition. Event ID: Facility ID: 675543 If continuation sheet Page 4 of 46 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 10/07/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for 1 of 5 Halls (400 Hall) 22 of 22 residents (CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) reviewed for neglect.- On [DATE] the facility failed to timely extinguish the fire when CR #44 was engulfed in flames and failed to assess and render aid to CR #44 after the fire was extinguished. The resident expired in the facility immediately after the fire.- The facility failed to take action for over 6 months when it knew after activation of the fire system, control access doors locked and prevented staff from entering to provide services to residents in the 400 Hall without the use of a code. During a fire on [DATE], while CR #44 was engulfed in flames, staff could not access the 400 Hall to provide aide to CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61 and Resident #66 for 3 minutes when the doors closed and locked with only CNA F on the hall.- The facility failed to ensure staff knew the unlocking mechanisms for controlled access doors in the facility that could prevent them from providing services to residents during emergency circumstances like fires. An Immediate Jeopardy was identified on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 05:00 PM. While the immediacy was removed on [DATE], at 04:54 PM, the facility remained out of compliance at a severity level of no actual harm, with a potential for more than minimal harm that was not an immediate jeopardy, and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of potential smoke inhalation, fire-related burns, debilitating injuries and death. Findings included Observation of the facility time stamped security footage of the front hall dated [DATE] revealed, at 01:16 AM staff at the nursing station looked around with the doors open to the 400 Hall. At 01:17 AM staff in a blue top and black pants (CNA D) walked into the 400 Hall and shortly after 2 staff one in all black (CNA P) and one in blue walked toward the 400 Hall when CNA D runs out from the 400 Hall and to the nursing station. The staff in blue moved out of frame towards the 500/600 Hall, while CNA P walked into the 400 Hall and CNA D entered the med room located behind the nursing station, grabbed the fire extinguisher and walked into the 400 Hall. The staff in blue and 1 other staff walk into the 400 Hall behind her with the staff in blue holding the door. At 01:18 AM staff in a pink jacket (LVN I) comes out of the 400 Hall and walked in a fast pace out of frame towards the [DATE] Hall and the staff in the blue is seen at the front door looking into the 400 Hall with her hands over her mouth as a resident (Resident #4) walked out pushing her wheelchair. As Resident #4 came out of the 400 Hall the door is seen to hit her and the staff in blue held the door open and then entered the 400 hall. CNA D runs out of the 400 Hall followed by 1 other staff and was seen on the phone as the other staff moved out of frame by the 500/600 Hall. At this time Resident 4 was alone, standing while holding her wheelchair immediately in front of the 400 Hall, when CNA P walked out followed by the staff in blue. CNA P walked back into the 400 Hall and out again and the doors to the 400 Hall slowly closed behind her at 01:18:52 AM. At 01:19 AM, the staff realized the door was closed, banged on the door and attempted were seen entering a code at a keypad. At this time, LVN I entered codes at the door to the 400 Hall with 2 other staff, CNA D was on the phone at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 5 of 46 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 10/07/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some nursing station with the staff in blue, and CNA P runs out the door with another staff. Resident #4 sat in her wheelchair in the front hall and received no assessments or evaluation as staff moved in and out of frame. At 1:21 AM an unknown resident (unknown resident #1) in a wheelchair moved toward the door of the 400 Hall, appeared to enter a code on the keypad and the door opened at 01:21: 53 AM (3 minutes after closing and 5 minutes after staff were alerted of the fire) and CNA P ran to the 400 Hall doors, held it open and smoke is seen coming out at the top the door. At 01:22:09 a resident (unknown resident #2) walked out the door, CNA P, CNA D and another staff enter into the 400 Hall as the staff in blue attempted to push the 2nd door in the double door to the 400 Hall. The door did not open and Resident #4 and unknown resident #1 who opened the door are wheeled out of frame toward the 500/600 Hall. At 01:23 AM CNA D is seen wheeling an unknown resident out the front door while unknown resident #2 is seen walking around the hall as smoke is seen coming out of the 400 Hall. CNA D, CNA P, the staff in blue, LVN I and other staff wheeled other residents out the front door until 01:26 AM when fully geared fire men arrived and entered the 400 Hall. At 01:28 AM the firefighters exit the 400 Hall and return into the hall and at 01:29 AM the EMTs arrive and enter into the 400 Hall. More firefighters arrived, moved in and out of the unit, at 1:33 AM (6 minutes after the fire was identified) an EMT walked out of the 400 Hall, while a fire fighter pushed against the 2nd door to the double doored 400 Hall that remained locked in place during this incident. Fire men turned sideways as they carried their equipment and walked through the single door open in the double doors to the 400 Hall and on and off attempted to open the locked door. Record review of the Fired Department NFIRS-1 Basic report dated [DATE] revealed, the fire department arrived to the facility on [DATE] at 01:33 PM (a 7 minute discrepancies from the facility's timestamped video) for a building fire.Actions taken: evacuate area and ventilate.- Casualties: 1 civilian and no injuries- Hazardous Materials Release: None- Property Use: Nursing HomeRemarks: Dispatched to a nursing home on fire. [fire department staff] were the first to arrive on scene of a 1-story pitched roofbuilding with nothing showing from the exterior. residents were being evacuated by building personnel. [fire department staff]assumed [facility] road command. [fire department staff] was ordered to investigate and reports a haze inside the building. [fire department staff] arrived and was ordered to assist with evacuation & prepare for horizontal ventilation. [fire department staff] reports a [location of fire] was found and the fire is out. [fire department staff] arrived and were ordered to assist with evacuationand ventilation. [fire department staff] were disregarded. arson was requested. [fire department staff] arrived and was assigned toevacuation group. [fire department staff] reports 11 residents were protected in place, haze is clearing out, and the room the 10-50 is in has been secured. the incident was tapped out holding [fire department staff] , [fire department staff] , [fire department staff] , & [fire department staff] . building personnel report the fire alarm was triggered and went to the wing to find the source of the alarm. CNA D was the 1st to find the source and used a fire extinguisher. the [location of fire] was in a 2-person room. the 2nd resident wasevacuated by building personnel. the small fire looks to have started on the bed near the victims head. There was no extension beyond the items on the bed. building personnel report the deceased is a smoker, but no one witnessed how the fire started. no signs of medical oxygen use in the room. a pump can was used to apply a small amount of water on a small book that was next to the deceased . [police department] units arrive .- Ignition: 21-Bedroom - < 5 persons- Area of Fire Origin: Undetermined- Heat Source: Undetermined- Item First Ignited: Undetermined- Cause of Ignition: Cause Under Investigation- Factors Contributing to Ignition: Undetermined- Human Factors Contributing to Ignition: Asleep- Mobile Property Involved: None- Fire Spread: Confined to Object of Origin- Presence of Detectors: Present- Detector Type: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 6 of 46 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 10/07/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Smoke- Detector Operation: Operated- Detector Effectiveness: Alerted Occupants, Occupants RespondedPresence of Automatic Extinguishing System: Present- Operation of Automatic Extinguishing System: Fire Too Small To Activate- [fire department staff]: arrived and was assigned evacuation group. Some patients were evacuated from building and 11 were sheltered in place. [fire department staff]- observed that the deceased pt appeared to not have any oxygen because of the absence of o2 bottle or o2 bib on the wall. notified command and secured the room.- [fire department staff]: arrived on location and was ordered by fire department staff]to investigate. upon entry we found the fire alarm system to be active and there was smoke in the lobby area. nursing home staff were evacuating residents. We made our way to the fire room and found one deceased victim in the first bed. i appears the fire started in the bed she occupied. fire department staff]notified command and we then assisted fire department staff] and fire department staff]with ventilating that wing of thenursing home. we also checked on the other occupants on that hallway. due to smoke conditions the rest of the hallway was sheltered in place. CR #44 Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The residents advanced directive was Full Code and she expired in the facility on [DATE] at 01:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left sided weaknessCare Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focus- requires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 ft 8 inches, and 274 lbs. Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers. Record review of CR #44's Discharge MDS dated [DATE] revealed, discharged Status- deceased . Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Clinical Assessments revealed, the last clinical assessment documented was on [DATE]. Record review of CR #44's Progress Notes revealed,- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the Hoyer Lift. Resident tolerated well.- [DATE] 01:54 AM signed by the DON, After speaking with the charge nurse and CNA, I called the RP's daughter to inform her that her mother was involved in a fire incident and that she was being treated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 7 of 46 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 10/07/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some for possible burns. Explained that the ambulance was working on [CR #44] at this time, and they would probably take her to the [Hospital]. The RP said she was not in town and that she would call her brother to see if he was closer than she was. RP said she would leave where she is and head to [Hospital] to check on her mother.- [DATE] 08:03 AM signed by LVN I, At approximately 01:00 AM the writer was on hall 600 to check on the other resident in my care. On my way back to 400, as I was walking down the hall I observed residents in bed sleeping including room [ROOM NUMBER]. As the writer was at the back of the hall 400, approximately 10 minutes later the writer heard alarm sound with flashing lights. I heard a CNA calling me and telling me the fire was in room [ROOM NUMBER]. As the writer was going to room [ROOM NUMBER], the CNA who was in front of me, grabbed the extinguisher and entered the room before I got there. When I entered the room I said to the CNA to call 911, then I assisted the CNA to evacuate the room-mate while the other 2 CNA's was trying to put the fire out. Once the roommate was safely evacuated, I immediately went to render aide to [CR #44]. As I was getting ready to assess the resident 911 was already here and in the room. The EMT's asked where the other resident was, and I told them she was outside. EMT's were providing medical care to [CR #44] and I left the room to go be with the residents that were outside. I then notified the DON once the residents were evacuated off of the hall and accounted for.- [DATE] 10:21 AM signed by MA C, resident expired. In an interview on [DATE] at 01:27 PM, CNA M said CR #44 did not exhibit any behaviors such as hoarding or hiding items, she was a smoker but she was complaint with the facility smoking policy. CNA M said there were no issues with CR #44 smoking. In an interview on [DATE] at 01:28 PM, LVN C said CR #44 was bed/wheelchair bound, required total assistance with all ADLs, had left side paralysis but could eat with setup/assistance. She said while the resident was grumpy, sarcastic and refused care there were no issues hoarding or hiding times. CR #44 was compliant with the facility smoking policy and would only smoke in the designated area. An observation on [DATE] at 09:58 AM revealed, CR #44's room floor covered by white powder and the room had been cleared of contents. There were gloves and packs of Personal Cleaning Wipes on the floor and on the bed. An off-white metal bed lie closest to the entrance, with no mattress and visible black fire damage. The center of the headboard was warped and melted with black burn marks, black ash/soot was observed on the base of the headboard, bed frame, and on the floor. There was limited evidence of smoke damage on the walls and ceiling with wipe marks on the ceiling directly above CR #44's bed and an imprint caused by smoke on the wall were a something was hung that was now removed. An observation and interview on [DATE] at 01:35 PM revealed, a box containing resident cigarettes and lighters locked in the med room. A box of cigarettes bearing CR #44's initials contained 7 cigarettes. The [NAME] said CR #44 had no behaviors of hoarding or hiding of items like cigarettes. She said her only behavior was to make complaints about staff, and that behavior was in her care plan. The DON said CR #44 diligently followed facility smoking policy and she would wait for staff to take her out to smoke. In an interview on [DATE] at 03:31 PM, the Medical Director said she had been Medical Director in the facility for the last 1 1/2 to 2 years. She said if a resident had extensive burns, the facility would not initially treat the burns while in an emergency situation but would cover the resident with clean, dry sheets; monitor breathing and keep the resident warm after the fire was extinguished. She said a resident with severe burns would need specialized treatment that could only the hospital could provide but she would expect nursing facility staff to assess the residents signs, mainly the breathing. The Medical Director said to maintain a resident's life prior to arrival of EMS, staff must monitor vital signs and monitor alertness. Once the resident was moved away from the fire source, staff should make sure airway was clear, resident was breathing, provide oxygen if necessary, monitor the residents pulse and blood pressure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 8 of 46 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 10/07/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some until EMS arrive. The Medical Director said if assessments and aide was not rendered to a resident with severe burns the resident could go into shock and a lot of things could happen. She said a resident with severe burns to the upper chest with shallow breathing should not be left unattended and someone should be with a resident if they have severe burns. The Medical Director said nursing home staff can provide services to help sustain life until EMS arrives and the resident should be continuously monitored. In an interview on [DATE] at 04:15 PM, the DON said when an individual experienced extensive burns they must be immediately assessed. Bleeding should be stopped, the airway must be assessed for lung sounds, and vitals assessed. She said nursing staff must stay with the resident until help arrived, and part of the competency of a nurse is training on how to react in an emergency situation. The DON said prior to the fire on [DATE] staff were not trained on what do to if a resident had a severe burn, but they know what to do now. She said to her knowledge nursing staff did not assess CR #44 after the fire was extinguished. The DON said no one assessed CR #44 after the fire but they should have as it was a professional standard. When asked about the risk to residents if staff failed to assess them following extensive burns, the DON said based on her investigation, she thought CR #44 was expired when she was found on fire and no one told her the resident was moving and groaning at the time of the fire. She said, only god has the power over life and death, and if a resident expired it was in God's Hands. When pressed the [NAME] said treatment rendered to a resident with extensive burns was based on what the assessments yields, but staff should make sure the resident was breathing. In an interview on [DATE] at 03:25 PM, the ME said CR #44's cause of death was still pending but the resident suffered from 2nd (burn that damages the top layer of skin and part of the 2nd layer) and 3rd (burn that destroys the first three layers of skin and the fatty tissue) degree burns on her head, upper torso and extremities. She had significant charring (severe burn that has destroyed all layers of skin and may extend into underlying tissue caused by prolonged exposure to extreme heat that appears black or ash-gray) especially to the left side of her body not the right. There was soot deposition in her airway/bronchi, which indicated she was breathing while on fire. 26% of CR #44's body surface was burned. Resident #2 Record review of Resident #2's Face Sheet dated [DATE], revealed a 93- year- old female who admitted to the facility on 03/13/ 20 with diagnosis which included: Type 2 diabetes, COPD, dementia, epilepsy, and irregular heartbeat. Record review of Resident #2's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 0 out of 15. The resident had lower extremity functional limitations in range of motion used automobile chair and required maximum assistance for most ADL's. For mobility, the resident was either dependent or required maximum assistance. The resident was fully dependent on staff to propel in a motorized wheelchair for 50 to 150 feet. Record review of Resident #2's undated Care Plan revealed, Focus- Requires a wander guard bracelet and is at risk for injury from wandering in an unsafe environment; Interventions: Monitor resident in facility and document attempts to elope out of facility. Focus: ADL self-care performance deficit r/t impaired cognition, poor safety awareness. Ambulates without use of an assistive device. She will at times hold onto the rails in hallway. Resident may require increased assistance with transfers depending on level of surface she is transferring from. Interventions: requires assistance of one staff to turn and reposition in bed at regular intervals. Record review of Resident #2's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- Resident #2 requires assistance of 1 staff to turn and reposition in bed at regular intervals and as necessary; requires assistance with lying to sitting at times. Transfer- requires assistance of one staff for supervision to move between surfaces as tolerated. Resident # 2 May require assistance with sit to stand if sitting for prolonged period of time or level of surface. Resident #3 Record review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 9 of 46 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 10/07/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #3's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, paralysis following a stroke, dementia, anxiety disorder, and bed confinement status. Record review of Resident #3's Quarterly MDS dated 9/11 25 revealed, severely impaired cognition skills for daily decision making and impairments in functional limitations in range of motion for both sides of her upper and lower extremity. Record review of Resident #3's undated Care Plan revealed, Focus-Resident received oxygen as needed. The shortness of breath. Interventions: Monitor for signs and symptoms of respiratory distress- SOB, dyspnea, low O2, cyanosis, diaphoresis, changes in behavior. Record review of Resident #3's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- total dependence on staff for repositioning and turning in bed. Lying to Sitting on side of bed: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Roll Left and Right: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to lying: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to stand: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Toilet transfer: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transfer: total dependence on staff for transfer. An observation on [DATE] at 10:19 AM revealed, Resident #3 lying in bed with eyes closed, well-dressed well-groomed in no immediate distress. Resident #4 Record Review of Resident #4's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, generalized anxiety disorder, unspecified dementia with other behavioral disturbances, adjustment disorder, major depressive disorder, Constipation, bradycardia, and repeated false. Record review of Resident #4's BIMS assessment dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 10.Record review of Resident #4's undated Care Plan revealed, Focus- impaired cognitive function/dementia or impaired thoughtProcesses; Interventions: needs supervision/assistance with all decision making. Focus: impaired visual function r/t Glaucoma; Interventions: during activities provide the resident with items that have larger print and bigger pictures to promote participation. Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs; Interventions: partial/moderate assistance with upper and lower body dressing. Transfer- Supervision by 1 staff to move between surfaces, as necessary. Bed Mobility- Supervision by 1 staff to move between surfaces, as necessary.An observation and interview on [DATE] at 02:41 PM revealed, Resident #4 was well groomed, well dressed in no immediate distress in a wheelchair. The resident was not interviewable, she was confused and repeated that she did not want to spend a night. Resident #6 Record review of Resident #6's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis (weakness and paralysis), type 2 diabetes, difficulty swallowing, dementia, and anorexia. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The use of a manual wheelchair, total dependence on most ADL's, and total dependence for most functional abilities. Record review of Resident #6's undated Care Plan revealed, Focus: Impaired visual function; Interventions: notify where you are placing their items. Be consistent and cater to the resident's preference of item placement. Focus: ADL self-care performance deficit, requires staff assist with ADL cares, refused to get out of bed daily; Interventions: Bed Mobility: extensive assistance to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 10 of 46 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 10/07/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Record review of Resident #6's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Am observation on [DATE] at 10:20 AM revealed, Resident #6 well dressed, well-groomed lying in bed awake. The resident responded to the surveyor with head nods and indicated she needed help. Resident #11 Record review of Resident #11's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia, bipolar disorder, diabetes and hypertension. Record review of Resident #11's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, one sided upper extremity and 2 sided lower extremity functional limitations in range of motion. Use of a wheelchair, total dependence with most ADLs and all functional abilities, total dependence for use of a manual scooter. Record review of Resident #11's undated Care Plan revealed, ADL self-care performance deficit and requires maximum assistance with ADLs r/t activity intolerance, Alzheimer's, impaired balance and limited M=mobility Record review of Resident #11's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- lying to sitting on side of the bed- dependent helper does all the effort; roll left and rightsubstantial/maximal assistance helper does more than half of the effort. Sit to stand- dependent helper does all the effort. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more was required for the resident to complete the activity. Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Parkinsonism. epilepsy, hypertension, difficulty breathing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, short term and long term memory OK. And independent cognitive skills for daily decision making The use of a wheelchair, no upper or lower extremity functional limitations in range of motion, substantial or maximum assistance to total dependence for all ADL's and substantial maximum assistance to total dependence on staff for mobility. Record review of Resident #18's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Parkinson's Disease. Interventions: chair/bed-to-chair transfer: Resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Lying to sitting on side of bed: resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Roll left and right: resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Sit to lying: Resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 11 of 46 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 10/07/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary. Transfer: supervision by staff to move between surfaces Resident #25 Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure. Depression, dependence on dialysis, and dementia. The resident discharged to the hospital on [DATE]. Record review of Resident #25's Discharge MDS dated [DATE] revealed, Modified independence. Cognitive skills for daily decision making and set up or clean up assistance with most ADL's. As well as partial to moderate assistance with most functional abilities. Record review of Resident #25's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues,setup, and/or assistance with ADLs r/t dx dementia, anxiety, depression; InterventionsChair/bed-to-chair transfer: resident's usual independent - resident completes the activity with no assistance from a helper. Lying to sitting on side of bed- resident's usual independent - resident completes the activity with no assistance from a helper. Roll left and right- resident's usual independent - resident completes the activity with no assistance from a helper. Sit to lying- resident's usual independent - resident completes the activity with no assistance from a helper. Sit to Event ID: Facility ID: 675543 If continuation sheet Page 12 of 46 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 10/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 22 of 22 (CR #44, Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) reviewed for neglect. - The Administrator failed to report to the State Survey Agency a fire in the 400 Hall, in which 22 residents (Resident #2, Resident #3, Resident #4, Resident #6, Resident #11, Resident #18, Resident #20, Resident #25, Resident #28, Resident #36, Resident #38, Resident #39, Resident #43, Resident #47, Resident #48, Resident #54, Resident #56, Resident #58, Resident #60, Resident #61, Resident #66) were exposed to smoke and CR #44 expired, to the State Survey Agency within 2 hours. This failure could result in the state agency receiving late notification of alleged incidents of fire, resident injuries and resident deaths. Findings included: Record review of the HHSC TULIP (system to which providers report accidents and incidents) on [DATE] revealed, the facility reported a fire with a fatality on [DATE] at 05:15 AM via through an email. Reporter's Name and Title: [Administrator]; Date/Time the administrator first learned of the incident on [DATE] at 01:31 AM; Date/Time the incident occurred: [DATE], approximately 01:20 AM. This administrator was informed by the Director of Nursing that there was a fire in the facility. It was reported that a CNA saw smoke and identified a resident on fire. The fire was extinguished. The staff immediately contacted 911 and notified the DON and this Administrator. The resident's roommate was removed from the room and surrounding residents were relocated to other rooms in the facility. Upon arrival to the facility, this administrator was informed by a first response officer that the affected resident was pronounced deceased . Assessment Details: The date and time of the assessment: The resident expired Record review of the Intake Investigation Worksheet dated [DATE] revealed, the reporter states that the upper part of the resident was engulfed in flames, along with the upper left part of their bed. the fire was contained and was isolated to the resident (upper half/above the waist) and the bed. additional reporters stated that they spoke with arson investigators and ruled out the usage of cigarettes, smoking, electrical, cellphone, or parts from a lighter as the cause of the fire, at this time it is still unknown how the fire started. Observation of the facility time stamped security footage of the front hall dated [DATE] revealed, at 01:16 AM staff at the nursing station looked around with the doors open to the 400 Hall. At 01:17 AM staff in a blue top and black pants (CNA D) walked into the 400 Hall and shortly after 2 staff one in all black (CNA P) and one in blue walked toward the 400 Hall when CNA D runs out from the 400 Hall and to the nursing station. The staff in blue moved out of frame towards the 500/600 Hall, while CNA P walked into the 400 Hall and CNA D entered the med room located behind the nursing station, grabbed the fire extinguisher and walked into the 400 Hall. The staff in blue and 1 other staff walk into the 400 Hall behind her with the staff in blue holding the door. At 01:18 AM staff in a pink jacket (LVN I) comes out of the 400 Hall and walked in a fast pace out of frame towards the [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 13 of 46 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 10/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Hall and the staff in the blue is seen at the front door looking into the 400 Hall with her hands over her mouth as a resident (Resident #4) walked out pushing her wheelchair. As Resident #4 came out of the 400 Hall the door is seen to hit her and the staff in blue held the door open and then entered the 400 hall. CNA D runs out of the 400 Hall followed by 1 other staff and was seen on the phone as the other staff moved out of frame by the 500/600 Hall. At this time Resident 4 was alone, standing while holding her wheelchair immediately in front of the 400 Hall, when CNA P walked out followed by the staff in blue. CNA P walked back into the 400 Hall and out again and the doors to the 400 Hall slowly closed behind her at 01:18:52 AM. At 01:19 AM, the staff realized the door was closed, banged on the door and attempted were seen entering a code at a keypad. At this time, LVN I entered codes at the door to the 400 Hall with 2 other staff, CNA D was on the phone at the nursing station with the staff in blue, and CNA P runs out the door with another staff. Resident #4 sat in her wheelchair in the front hall and received no assessments or evaluation as staff moved in and out of frame. At 1:21 AM an unknown resident (unknown resident #1) in a wheelchair moved toward the door of the 400 Hall, appeared to enter a code on the keypad and the door opened at 01:21: 53 AM (3 minutes after closing and 5 minutes after staff were alerted of the fire) and CNA P ran to the 400 Hall doors, held it open and smoke is seen coming out at the top the door. At 01:22:09 a resident (unknown resident #2) walked out the door, CNA P, CNA D and another staff enter into the 400 Hall as the staff in blue attempted to push the 2nd door in the double door to the 400 Hall. The door did not open and Resident #4 and unknown resident #1 who opened the door are wheeled out of frame toward the 500/600 Hall. At 01:23 AM CNA D is seen wheeling an unknown resident out the front door while unknown resident #2 is seen walking around the hall as smoke is seen coming out of the 400 Hall. CNA D, CNA P, the staff in blue, LVN I and other staff wheeled other residents out the front door until 01:26 AM when fully geared fire men arrived and entered the 400 Hall. At 01:28 AM the firefighters exit the 400 Hall and return into the hall and at 01:29 AM the EMTs arrive and enter into the 400 Hall. More firefighters arrived, moved in and out of the unit, at 1:33 AM (6 minutes after the fire was identified) an EMT walked out of the 400 Hall, while a fire fighter pushed against the 2nd door to the double doored 400 Hall that remained locked in place during this incident. Fire men turned sideways as they carried their equipment and walked through the single door open in the double doors to the 400 Hall and on and off attempted to open the locked door. Record review of the Fired Department NFIRS-1 Basic report dated [DATE] revealed, the fire department arrived to the facility on [DATE] at 01:33 PM (a 7 minute discrepancies from the facility's timestamped video) for a building fire. - Actions taken: evacuate area and ventilate.- Casualties: 1 civilian and no injuries- Hazardous Materials Release: None- Property Use: Nursing HomeRemarks: Dispatched to a nursing home on fire. [fire department staff] were the first to arrive on scene of a 1-story pitched roofbuilding with nothing showing from the exterior. residents were being evacuated by building personnel. [fire department staff]assumed [facility] road command. [fire department staff] was ordered to investigate and reports a haze inside the building. [fire department staff] arrived and was ordered to assist with evacuation & prepare for horizontal ventilation. [fire department staff] reports a [location of fire] was found and the fire is out. [fire department staff] arrived and were ordered to assist with evacuationand ventilation. [fire department staff] were disregarded. arson was requested. [fire department staff] arrived and was assigned toevacuation group. [fire department staff] reports 11 residents were protected in place, haze is clearing out, and the room the 10-50 is in has been secured. the incident was tapped out holding [fire department staff] , [fire department staff] , [fire department staff] , & [fire department staff] . building personnel report the fire alarm was triggered and went to the wing to find the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 14 of 46 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 10/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few source of the alarm. CNA D was the 1st to find the source and used a fire extinguisher. the [location of fire] was in a 2-person room. the 2nd resident wasevacuated by building personnel. the small fire looks to have started on the bed near the victims head. There was no extension beyond the items on the bed. building personnel report the deceased is a smoker, but no one witnessed how the fire started. no signs of medical oxygen use in the room. a pump can was used to apply a small amount of water on a small book that was next to the deceased . [police department] units arrive .- Ignition: 21-Bedroom - < 5 persons- Area of Fire Origin: Undetermined- Heat Source: Undetermined- Item First Ignited: Undetermined- Cause of Ignition: Cause Under Investigation- Factors Contributing to Ignition: Undetermined- Human Factors Contributing to Ignition: Asleep- Mobile Property Involved: None- Fire Spread: Confined to Object of Origin- Presence of Detectors: Present- Detector Type: Smoke- Detector Operation: Operated- Detector Effectiveness: Alerted Occupants, Occupants Responded- Presence of Automatic Extinguishing System: Present- Operation of Automatic Extinguishing System: Fire Too Small To Activate- [fire department staff]: arrived and was assigned evacuation group. Some patients were evacuated from building and 11 were sheltered in place. [fire department staff]- observed that the deceased pt appeared to not have any oxygen because of the absence of o2 bottle or o2 bib on the wall. notified command and secured the room.- [fire department staff]: arrived on location and was ordered by fire department staff]to investigate. upon entry we found the fire alarm system to be active and there was smoke in the lobby area. nursing home staff were evacuating residents. We made our way to the fire room and found one deceased victim in the first bed. i appears the fire started in the bed she occupied. fire department staff]notified command and we then assisted fire department staff] and fire department staff]with ventilating that wing of thenursing home. we also checked on the other occupants on that hallway. due to smoke conditions the rest of the hallway was sheltered in place. CR #44 Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The residents advanced directive was Full Code and she expired in the facility on [DATE] at 01:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left sided weakness Care Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focusrequires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 ft 8 inches, and 274 lbs. Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers. Record review of CR #44's Discharge MDS dated [DATE] revealed, discharged Status(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 15 of 46 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 10/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few deceased . Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Clinical Assessments revealed, the last clinical assessment documented was on [DATE]. Record review of CR #44's Progress Notes revealed,- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the Hoyer Lift. Resident tolerated well.- [DATE] 01:54 AM signed by the DON, After speaking with the charge nurse and CNA, I called the RP's daughter to inform her that her mother was involved in a fire incident and that she was being treated for possible burns. Explained that the ambulance was working on [CR #44] at this time, and they would probably take her to the [Hospital]. The RP said she was not in town and that she would call her brother to see if he was closer than she was. RP said she would leave where she is and head to [Hospital] to check on her mother.- [DATE] 08:03 AM signed by LVN I, At approximately 01:00 AM the writer was on hall 600 to check on the other resident in my care. On my way back to 400, as I was walking down the hall I observed residents in bed sleeping including room [ROOM NUMBER]. As the writer was at the back of the hall 400, approximately 10 minutes later the writer heard alarm sound with flashing lights. I heard a CNA calling me and telling me the fire was in room [ROOM NUMBER]. As the writer was going to room [ROOM NUMBER], the CNA who was in front of me, grabbed the extinguisher and entered the room before I got there. When I entered the room I said to the CNA to call 911, then I assisted the CNA to evacuate the room-mate while the other 2 CNA's was trying to put the fire out. Once the roommate was safely evacuated, I immediately went to render aide to [Resident #24]. As I was getting ready to assess the resident 911 was already here and in the room. The EMT's asked where the other resident was, and I told them she was outside. EMT's were providing medical care to [Resident #24] and I left the room to go be with the residents that were outside. I then notified the DON once the residents were evacuated off of the hall and accounted for.- [DATE] 10:21 AM signed by MA C, resident expired. In an interview on [DATE] at 01:27 PM, CNA M said CR #44 did not exhibit any behaviors such as hoarding or hiding items, she was a smoker but she was complaint with the facility smoking policy. CNA M said there were no issues with CR #44 smoking. In an interview on [DATE] at 01:28 PM, LVN C said CR #44 was bed/wheelchair bound, required total assistance with all ADLs, had left side paralysis but could eat with setup/assistance. She said while the resident was grumpy, sarcastic and refused care there were no issues hoarding or hiding times. CR #44 was compliant with the facility smoking policy and would only smoke in the designated area. An observation on [DATE] at 09:58 AM revealed, CR #44's room floor covered by white powder and the room had been cleared of contents. There were gloves and packs of Personal Cleaning Wipes on the floor and on the bed. An off-white metal bed lie closest to the entrance, with no mattress and visible black fire damage. The center of the headboard was warped and melted with black burn marks, black ash/soot was observed on the base of the headboard, bed frame, and on the floor. There was limited evidence of smoke damage on the walls and ceiling with wipe marks on the ceiling directly above CR #44's bed and an imprint caused by smoke on the wall were a something was hung that was now removed. An observation and interview on [DATE] at 01:35 PM revealed, a box containing resident cigarettes and lighters locked in the med room. A box of cigarettes bearing CR #44's initials contained 7 cigarettes. The [NAME] said CR #44 had no behaviors of hoarding or hiding of items like cigarettes. She said her only behavior was to make complaints about staff, and that behavior was in her care plan. The DON said CR #44 diligently followed facility smoking policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 16 of 46 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 10/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and she would wait for staff to take her out to smoke. In an interview on [DATE] at 03:31 PM, the Medical Director said she had been Medical Director in the facility for the last 1 1/2 to 2 years. She said if a resident had extensive burns, the facility would not initially treat the burns while in an emergency situation but would cover the resident with clean, dry sheets; monitor breathing and keep the resident warm after the fire was extinguished. She said a resident with severe burns would need specialized treatment that could only the hospital could provide but she would expect nursing facility staff to assess the residents signs, mainly the breathing. The Medical Director said to maintain a resident's life prior to arrival of EMS, staff must monitor vital signs and monitor alertness. Once the resident was moved away from the fire source, staff should make sure airway was clear, resident was breathing, provide oxygen if necessary, monitor the residents pulse and blood pressure until EMS arrive. The Medical Director said if assessments and aide was not rendered to a resident with severe burns the resident could go into shock and a lot of things could happen. She said a resident with severe burns to the upper chest with shallow breathing should not be left unattended and someone should be with a resident if they have severe burns. The Medical Director said nursing home staff can provide services to help sustain life until EMS arrives and the resident should be continuously monitored. In an interview on [DATE] at 04:15 PM, the DON said when an individual experienced extensive burns they must be immediately assessed. Bleeding should be stopped, the airway must be assessed for lung sounds, and vitals assessed. She said nursing staff must stay with the resident until help arrived, and part of the competency of a nurse is training on how to react in an emergency situation. The DON said prior to the fire on [DATE] staff were not trained on what do to if a resident had a severe burn, but they know what to do now. She said to her knowledge nursing staff did not assess CR #44 after the fire was extinguished. The DON said no one assessed CR #44 after the fire but they should have as it was a professional standard. When asked about the risk to residents if staff failed to assess them following extensive burns, the DON said based on her investigation, she thought CR #44 was expired when she was found on fire and no one told her the resident was moving and groaning at the time of the fire. She said, only god has the power over life and death, and if a resident expired it was in God's Hands. When pressed the [NAME] said treatment rendered to a resident with extensive burns was based on what the assessments yields, but staff should make sure the resident was breathing. In an interview on [DATE] at 03:25 PM, the ME said CR #44's cause of death was still pending but the resident suffered from 2nd (burn that damages the top layer of skin and part of the 2nd layer) and 3rd (burn that destroys the first three layers of skin and the fatty tissue) degree burns on her head, upper torso and extremities. She had significant charring (severe burn that has destroyed all layers of skin and may extend into underlying tissue caused by prolonged exposure to extreme heat that appears black or ash-gray) especially to the left side of her body not the right. There was soot deposition in her airway/bronchi, which indicated she was breathing while on fire. 26% of CR #44's body surface was burned. Resident #2 Record review of Resident #2's Face Sheet dated [DATE], revealed a 93- year- old female who admitted to the facility on 03/13/ 20 with diagnosis which included: Type 2 diabetes, COPD, dementia, epilepsy, and irregular heartbeat. Record review of Resident #2's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 0 out of 15. The resident had lower extremity functional limitations in range of motion used automobile chair and required maximum assistance for most ADL's. For mobility, the resident was either dependent or required maximum assistance. The resident was fully dependent on staff to propel in a motorized wheelchair for 50 to 150 feet. Record review of Resident #2's undated Care Plan revealed, Focus- Requires a wander guard bracelet and is at risk for injury from wandering in an unsafe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 17 of 46 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 10/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few environment; Interventions: Monitor resident in facility and document attempts to elope out of facility. Focus: ADL self-care performance deficit r/t impaired cognition, poor safety awareness. Ambulates without use of an assistive device. She will at times hold onto the rails in hallway. Resident may require increased assistance with transfers depending on level of surface she is transferring from. Interventions: requires assistance of one staff to turn and reposition in bed at regular intervals. Record review of Resident #2's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- Resident #2 requires assistance of 1 staff to turn and reposition in bed at regular intervals and as necessary; requires assistance with lying to sitting at times. Transfer- requires assistance of one staff for supervision to move between surfaces as tolerated. Resident # 2 May require assistance with sit to stand if sitting for prolonged period of time or level of surface. Resident #3 Record review of Resident #3's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, paralysis following a stroke, dementia, anxiety disorder, and bed confinement status. Record review of Resident #3's Quarterly MDS dated 9/11 25 revealed, severely impaired cognition skills for daily decision making and impairments in functional limitations in range of motion for both sides of her upper and lower extremity. Record review of Resident #3's undated Care Plan revealed, Focus-Resident received oxygen as needed. The shortness of breath. Interventions: Monitor for signs and symptoms of respiratory distressSOB, dyspnea, low O2, cyanosis, diaphoresis, changes in behavior. Record review of Resident #3's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- total dependence on staff for repositioning and turning in bed. Lying to Sitting on side of bed: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Roll Left and Right: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to lying: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to stand: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Toilet transfer: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transfer: total dependence on staff for transfer. An observation on [DATE] at 10:19 AM revealed, Resident #3 lying in bed with eyes closed, well-dressed well-groomed in no immediate distress. Resident #4 Record Review of Resident #4's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, generalized anxiety disorder, unspecified dementia with other behavioral disturbances, adjustment disorder, major depressive disorder, Constipation, bradycardia, and repeated false. Record review of Resident #4's BIMS assessment dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 7 out of 10.Record review of Resident #4's undated Care Plan revealed, Focus- impaired cognitive function/dementia or impaired thoughtProcesses; Interventions: needs supervision/assistance with all decision making. Focus: impaired visual function r/t Glaucoma; Interventions: during activities provide the resident with items that have larger print and bigger pictures to promote participation. Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs; Interventions: partial/moderate assistance with upper and lower body dressing. TransferSupervision by 1 staff to move between surfaces, as necessary. Bed Mobility- Supervision by 1 staff to move between surfaces, as necessary.An observation and interview on [DATE] at 02:41 PM revealed, Resident #4 was well groomed, well dressed in no immediate distress in a wheelchair. The resident was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 18 of 46 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 10/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interviewable, she was confused and repeated that she did not want to spend a night. Resident #6 Record review of Resident #6's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis (weakness and paralysis), type 2 diabetes, difficulty swallowing, dementia, and anorexia. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The use of a manual wheelchair, total dependence on most ADL's, and total dependence for most functional abilities. Record review of Resident #6's undated Care Plan revealed, Focus: Impaired visual function; Interventions: notify where you are placing their items. Be consistent and cater to the resident's preference of item placement. Focus: ADL self-care performance deficit, requires staff assist with ADL cares, refused to get out of bed daily; Interventions: Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Record review of Resident #6's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of Hoyer lift Am observation on [DATE] at 10:20 AM revealed, Resident #6 well dressed, well-groomed lying in bed awake. The resident responded to the surveyor with head nods and indicated she needed help. Resident #11 Record review of Resident #11's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia, bipolar disorder, diabetes and hypertension. Record review of Resident #11's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, one sided upper extremity and 2 sided lower extremity functional limitations in range of motion. Use of a wheelchair, total dependence with most ADLs and all functional abilities, total dependence for use of a manual scooter. Record review of Resident #11's undated Care Plan revealed, ADL self-care performance deficit and requires maximum assistance with ADLs r/t activity intolerance, Alzheimer's, impaired balance and limited M=mobility Record review of Resident #11's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- lying to sitting on side of the bed- dependent helper does all the effort; roll left and right- substantial/maximal assistance helper does more than half of the effort. Sit to stand- dependent helper does all the effort. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more was required for the resident to complete the activity. Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Parkinsonism. epilepsy, hypertension, difficulty breathing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, short term and long term memory OK. And independent cognitive skills for daily decision making The use of a wheelchair, no upper or lower extremity functional limitations in range of motion, substantial or maximum assistance to total dependence for all ADL's and substantial maximum assistance to total dependence on staff for mobility. Record review of Resident #18's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Parkinson's Disease. Interventions: chair/bed-to-chair transfer: Resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Lying to sitting on side of bed: resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Roll left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 19 of 46 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 10/07/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and right: resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Sit to lying: Resident's usual performance is partial/moderate assistance helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder. Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary. Transfer: supervision by staff to move between surfaces Resident #25 Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure. Depression, dependence on dialysis, and dementia. The resident Event ID: Facility ID: 675543 If continuation sheet Page 20 of 46 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 10/07/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure that assessments accurately reflected residents' status for 2 (CR #44 and Resident #28) of 6 residents reviewed for accuracy of assessments. The failed to ensure CR #44's left sided hemiplegia and hemiparesis (paralysis and weakness was documented accurately in her Quarterly MDS dated [DATE] as a functional limitation in range of motion and diagnosis.The facility failed to ensure that Resident #28's behavior of wandering was documented on their quarterly MDS assessment dated [DATE].Findings included:Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The resident expired in the facility on [DATE] at 1:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left side weakness Care Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focus- requires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 feet 8 inches, and 274 lbs.Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers.Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Progress Notes revealed the following;- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the mechanical Lift. Resident CR#44 tolerated well.In an interview on [DATE] at 01:28 PM, LVN C said CR #44 was bed/wheelchair bound, required total assistance with all ADLs, had left sided paralysis but could eat with setup/assistance. She said while the resident was grumpy, sarcastic and refused care there were no issues hoarding or hiding times. CR #44 was compliant with the facility smoking policy and would only smoke in the designated area.During interview on [DATE] at 12:39 PM, CNA L said she usually worked on the #400 hallway which was where CR #44 had resided. CR #44's left arm and leg were paralyzed, she could move her right side perfectly fine but not her left side . CNA L said CR #44 transferred out of bed to a wheelchair by using a Hoyer lift and two-person assistance. In an interview on [DATE] at 12:42 PM., LVN E said CR #44 suffered from paralysis from a previous CNA and had left sided weakness with no movement on her left side. LVN E said CR #44 was a two Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 21 of 46 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 10/07/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete person assist and was transferred using a Hoyer lift. In an interview on [DATE] at 08:24 PM, the MDS Nurse said she was responsible for completing all facility MDSs. She said the MDA represents the resident's status and is usually a 7 day look back period. She said a resident's functional limitation in range of motion documents how a resident performs their day to day activities. She said failure to have the correct diagnosis or an incorrect MDS placed residents at risk for missed services and an inaccurate plan of care. The MDS said CR #44 had paralysis on one side of her body. After she reviewed the MDS, she said CR #44's MDS was coded incorrectly because it did not document her paralysis as a functional limitation of range of motion. She said she was responsible for completing CR #44's diagnosis, MDS and care plan and the errors were an oversight.Record review of Resident #28's face sheet dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities).Record review of Resident #28's quarterly MDS dated [DATE] revealed a BIMS score of 0 that indicated severe cognitive impairment. Record review of Resident #28's unmodified quarterly MDS dated [DATE] revealed wandering behavior was not exhibited in Section E. Record review of Resident #28's modified quarterly MDS dated [DATE] of Section E revealed wandering behavior occurred 1 to 3 days. Section P revealed daily use of wander/elopement alarm.Record review of Resident #28's Order Summary Report as of [DATE] revealed WANDER DEVICE: Wander device alarm applied with order date of [DATE]. Record review of Resident #28's care plan with revision date of [DATE] and target date of [DATE] revealed Resident #28 was care planned with a focus of requiring a wander guard bracelet and was at risk for injury from wandering. Record review of Resident #28's Elopement Risk Screener dated [DATE] revealed Resident #28 had a wandering history but had never eloped. Record review of Resident #28's [DATE] TAR revealed task from 9/1-[DATE] to visually check placement of Wandering Alert Device every shift from 9/1-[DATE].Observation on [DATE] at 12:24 p.m. revealed Resident #28 walking up and down the #400 hallwayDuring interview on [DATE] at 2:15 p.m., CNA M said Resident #28 walked a lot and would walk back and forth in every hallway. Observation on [DATE] at 2:19 p.m. revealed Resident #28 walking down the #100 hallway when her room was on the #400 hallway. During interview on [DATE] at 2:33 p.m., MDS RN said the Social Services Director completed Section E of the MDS and showed the surveyor Section P where use of wander/elopement alarm was captured. During interview on [DATE] at 2:41 p.m., the DON said she was familiar with Resident #28, and she walks all day. The DON said the MDS RN was responsible for completing the MDS. The DON said if the MDS was not accurate it was not a direct accurate reflection of who the resident was. During interview on [DATE] at 2:47 p.m., the MDS RN said she was going to modify Resident #28's MDS. During interview on [DATE] at 4:07 p.m., the Social Services Director answered yes when asked if Resident #28 wandered. The Social Services Director said she completed sections B, C, D, E and Q of the MDS. The Social Services Director said she documented that wandering behavior was not exhibited as Resident #28 walks the hallways but did not wander outside. The Social Services Director said Resident #28 had a wanderguard and she was not sure what happened prior for Resident #28 to get the wanderguard. The Social Services Director said something must have happened for the resident to be at risk for the wanderguard. The Social Services Director said if the MDS did not reflect the resident accurately then that was false information because you would not be looking for those behaviors. Record review of the facility's policy MDS 3.0 Completion dated 2023 revealed According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity. Event ID: Facility ID: 675543 If continuation sheet Page 22 of 46 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 10/07/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for 1(Resident #11) of 6 residents reviewed for care plan.Resident #11's care plan printed 9/30/25 was not revised to reflect removal of a urinary catheter with an order to remove the foley catheter on 8/13/24 and when a pressure ulcer wound resolved with a discontinued order dated 9/1/25. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being. Findings included:Record review of Resident #11's face sheet dated 10/1/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Other Schizophrenia (disorder characterized by hallucinations, delusions, disorganized thinking and difficulty distinguishing reality from imagination).Record review of Resident #11's quarterly MDS dated [DATE] revealed a BIMS score of 9 that indicated moderate cognitive impairment. Section H revealed Resident #11 did not have an indwelling catheter. Section M revealed 1 number of Stage 3 pressure ulcers. Record review of Resident #11's discontinued orders revealed wound care to left lower extremity with end date on 9/1/25 and order to remove Foley catheter on 8/13/24.Record review of Resident #11's August 2025 MAR revealed Remove Foley catheter with documentation on 8/13/25.Record review of Resident #11's Progress Note dated 8/13/25 at 11:37 p.m. revealed Resident #11's Foley catheter was removed at 9:45 p.m. Record review of Resident #11's Weekly Wound Observation dated 8/28/25 revealed Stage 3 pressure ulcer to left distal posterior lower leg that was closed, and wound progress was resolved. Record review of Resident #11's care plan printed 9/30/25 revealed a focus of an indwelling suprapubic catheter and actual impairment to skin integrity from a left lower leg pressure ulcer. Record review of Resident #11's order Summary Report as of 10/1/25 did not reveal any orders regarding a catheter or wound care for left lower leg pressure ulcer.Record review of Resident #11's Skin Observation dated 10/1/25 revealed no documentation regarding pressure ulcers with only documentation regarding rashes. Record review of Resident #11's care plan printed 10/3/25 no longer had a focus if an indwelling suprapubic catheter or actual impairment to skin integrity from a left lower leg pressure ulcer. This care plan was revised after surveyor intervention. Observation on 9/29/25 at 10:21 a.m. of Resident #11 revealed no visible catheter. During an interview on 9/29/25 at 11:59 a.m., LVN C said she had been the wound care nurse for the last two weeks and would be the wound care nurse for the next two weeks and then there would be someone coming to be the wound care nurse. During an interview on 9/29/25 at 12:27 p.m., LVN E said Resident #11 did not have a suprapubic catheter. During an interview on 9/29/25 at 12:39 p.m., CNA L said Resident #11 did not have a catheter. During an interview on 10/3/25 at 2:22 p.m., LVN F said if a catheter was removed or it a wound resolved then she would relay the message to the wound care nurse or ADON and they would update the care plan. During an interview on 10/3/25 at 2:33 p.m., MDS RN said the DON and ADON was who made changes to the care plan like if a resident's catheter was removed. During an interview on 10/3/25 at 2:41 p.m., DON said the nurse on the unit, herself or the ADON, was responsible for updating care plans like when a Foley catheter was removed. The DON said the wound care nurse, ADON or herself would be responsible for updating the care plan when a wound was resolved. The DON said if the care plan was not revised that it did not directly reflect the care that they were providing to Resident #11. At 3:03 p.m., the DON went to check Resident #11 as the DON said she was still learning the residents and confirmed that Resident #11 did not have a catheter. At 3:05 p.m., the DON said she removed the catheter from Resident #11's care plan. The DON said a wound should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 23 of 46 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 10/07/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete come off the resident's care plan when the wound was resolved. During an interview on 10/3/25 at 3:10 p.m., ADON said she completed the baseline care plans for new admissions. ADON said the previous DON preferred to update the care plans and attended the care plan meetings. ADON said the MDS RN was responsible for completing the MDS. During an interview on 10/3/25 at 5:23 p.m., LVN C, who was the current wound care nurse, said she was only responsible for wound care and not updating the resident's care plans. LVN C said probably DON or ADON was responsible for updating the residents' care plans regarding wound care. Record review of facility's policy Comprehensive Care Plans dated 2025 revealed The comprehensive care plans will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Event ID: Facility ID: 675543 If continuation sheet Page 24 of 46 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 10/07/2025 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 - 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 ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 13 of 22 residents (CR #44, Resident #2 Resident #3, Resident #6, Resident #11, Resident #18, Resident #20, Resident #36, Resident #43, Resident #48, Resident #54, Resident #58, and Resident #60) and 1 of 4 Halls (400 Hall) reviewed for quality of care.- Facility staff failed to immediately put out CR #44 when she was engulfed in flames with a fire extinguisher, a non-fire retardant blanket was used that worsened the fire. After the fire was extinguished staff failed to assess and render aide to CR #44. The resident expired in the facility immediately after the fire.- Facility failed to follow the facility fire safety plan when evacuating residents from the 400 hall by leaving Resident #2 Resident #3, Resident #6, Resident #11, Resident #18, Resident #20, Resident #36, Resident #43, Resident #48, Resident #54, Resident #58, and Resident #60 in their rooms during a fire on [DATE] which resulted in prolonged exposure to smoke. An Immediate Jeopardy was identified on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 11:20 AM. While the IJ was removed on [DATE], at 04:54 PM, the facility remained out of compliance at a severity level of no actual harm, with a potential for more than minimal harm that was not an immediate jeopardy, and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving care and services needed to meet their needs Findings included Observation of the facility time stamped security footage of the front hall dated [DATE] revealed, at 01:16 AM staff at the nursing station looked around with the doors open to the 400 Hall. At 01:17 AM staff in a blue top and black pants (CNA D) walked into the 400 Hall and shortly after 2 staff one in all black (CNA P) and one in blue walked toward the 400 Hall when CNA D runs out from the 400 Hall and to the nursing station. The staff in blue moved out of frame towards the 500/600 Hall, while CNA P walked into the 400 Hall and CNA D entered the med room located behind the nursing station, grabbed the fire extinguisher and walked into the 400 Hall. The staff in blue and 1 other staff walk into the 400 Hall behind her with the staff in blue holding the door. At 01:18 AM staff in a pink jacket (LVN I) came out of the 400 Hall and walked in a fast pace out of frame towards the [DATE] Hall and the staff in the blue was seen at the front door looking into the 400 Hall with her hands over her mouth as a resident (Resident #4) walked out pushing her wheelchair. As Resident #4 came out of the 400 Hall the door is seen to hit her and the staff in blue held the door open and then entered the 400 hall. CNA D runs out of the 400 Hall followed by 1 other staff and was seen on the phone as the other staff moved out of frame by the 500/600 Hall. At this time Resident 4 was alone, standing while holding her wheelchair immediately in front of the 400 Hall, when CNA P walked out followed by the staff in blue. CNA P walked back into the 400 Hall and out again and the doors to the 400 Hall slowly closed behind her at 01:18:52 AM. At 01:19 AM, the staff realized the door was closed, banged on the door and were observed pressing a keypad. At this time, LVN I entered codes at the door to the 400 Hall with 2 other staff, CNA D was on the phone at the nursing station with the staff in blue, and CNA P ran out the door with another staff. Resident #4 sat in her wheelchair in the front hall and received no assessments or evaluation as staff moved in and out of frame. At 1:21 AM an unknown resident (unknown resident #1) in a wheelchair moved toward the door of the 400 Hall, appeared to enter a code on the keypad and the door opened at 01:21: 53 AM (3 minutes after closing and 5 minutes after staff were alerted of the fire) and CNA P ran to the 400 Hall doors, held it open and smoke Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 25 of 46 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 10/07/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some was seen coming out at the top the door. At 01:22:09 a resident (unknown resident #2) walked out the door, CNA P, CNA D and another staff enter into the 400 Hall as the staff in blue attempted to push the 2nd door in the double door to the 400 Hall. The door did not open and Resident #4 and unknown resident #1 who opened the door are wheeled out of frame toward the 500/600 Hall. At 01:23 AM CNA D was seen wheeling an unknown resident out the front door while unknown resident #2 is seen walking around the hall as smoke was seen coming out of the 400 Hall. CNA D, CNA P, the staff in blue, LVN I and other staff wheeled other residents out the front door until 01:26 AM when fully geared fire men arrived and entered the 400 Hall. At 01:28 AM the firefighters exit the 400 Hall and return into the hall and at 01:29 AM the EMTs arrive and enter into the 400 Hall. More firefighters arrived, moved in and out of the unit, at 1:33 AM (6 minutes after the fire was identified) an EMT walked out of the 400 Hall, while a fire fighter pushed against the 2nd door to the double doored 400 Hall that remained locked in place during this incident. Fire men turned sideways as they carried their equipment and walked through the single door open in the double doors to the 400 Hall and on and off attempted to open the locked door. Record review of the Fire Department NFIRS-1 Basic report dated [DATE] revealed, the fire department arrived to the facility on [DATE] at 01:33 PM (a 7 minute discrepancies from the facility's timestamped video) for a building fire.Actions taken: evacuate area and ventilate.- Casualties: 1 civilian and no injuries- Hazardous Materials Release: None- Property Use: Nursing HomeRemarks: Dispatched to a nursing home on fire. [fire department staff] were the first to arrive on scene of a 1-story pitched roof building with nothing showing from the exterior. residents were being evacuated by building personnel. [fire department staff] assumed [facility] road command. [fire department staff] was ordered to investigate and reports a haze inside the building. [fire department staff] arrived and was ordered to assist with evacuation & prepare for horizontal ventilation. [fire department staff] reports a [location of fire] was found and the fire is out. [fire department staff] arrived and were ordered to assist with evacuation and ventilation. [fire department staff] were disregarded. arson was requested. [fire department staff] arrived and was assigned to evacuation group. [fire department staff] reports 11 residents were protected in place, haze is clearing out, and the room the 10- 50 is in has been secured. the incident was tapped out holding [fire department staff] , [fire department staff] , [fire department staff] , & [fire department staff] . building personnel report the fire alarm was triggered and went to the wing to find the source of the alarm. CNA D was the 1st to find the source and used a fire extinguisher. the [location of fire] was in a 2-person room. the 2nd resident was evacuated by building personnel. the small fire looks to have started on the bed near the victims head. There was no extension beyond the items on the bed. building personnel report the deceased is a smoker, but no one witnessed how the fire started. no signs of medical oxygen use in the room. a pump can was used to apply a small amount of water on a small book that was next to the deceased . [police department] units arrive .Ignition: 21-Bedroom - < 5 persons- Area of Fire Origin: Undetermined- Heat Source: Undetermined- Item First Ignited: Undetermined- Cause of Ignition: Cause Under Investigation- Factors Contributing to Ignition: Undetermined- Human Factors Contributing to Ignition: Asleep- Mobile Property Involved: None- Fire Spread: Confined to Object of Origin- Presence of Detectors: Present- Detector Type: Smoke- Detector Operation: Operated- Detector Effectiveness: Alerted Occupants, Occupants Responded- Presence of Automatic Extinguishing System: Present- Operation of Automatic Extinguishing System: Fire Too Small To Activate- [fire department staff]: arrived and was assigned evacuation group. Some patients were evacuated from building and 11 were sheltered in place. [fire department staff]- observed that the deceased pt appeared to not have any oxygen because of the absence of o2 bottle or o2 bib on the wall. notified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 26 of 46 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 10/07/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some command and secured the room.- [fire department staff]: arrived on location and was ordered by [fire department staff] to investigate. upon entry we found the fire alarm system to be active and there was smoke in the lobby area. nursing home staff were evacuating residents. We made our way to the fire room and found one deceased victim in the first bed. i appears the fire started in the bed she occupied. fire department staff] notified command and we then assisted fire department staff] and fire department staff]with ventilating that wing of thenursing home. we also checked on the other occupants on that hallway. due to smoke conditions the rest of the hallway was sheltered in place. CR #44 Record review of CR #44's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: stroke, diabetes, depression, mild cognitive impairment, high cholesterol, acid reflux. CR #44's left side weakness or paralysis was not documented. The resident expired in the facility on [DATE] at 01:45 AM. Record review of CR #44's Facility Transfer Records dated [DATE] revealed, left sided weaknessCare Plan: Focus- history of stroke with residual left side weakness and is at risk of future stroke. Focus- requires assistance for ADLs and mobility tasks due to history of stroke with residual left side weakness, generalized weakness, poor endurance/activity tolerance. Record review of CR#44's Quarterly MDS dated [DATE], severe impairment as indicated by a BIMS 06 out of 15, no behaviors, no lower or upper extremity limitations in range of motion, use of a wheelchair, total dependence for most mobility (Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer and Toilet transfer. Substantial/maximal assistance to propel herself 50-150 feet with a manual wheelchair. CR #44 was 5 ft 8 inches, and 274 lbs. Record review of CR #44's undated Care Plan revealed, Focus- is a smoker and is at risk for smoking-related injury/incident; interventions: Educate the resident and/or resident representative on the established facility smoking schedule, designated facility smoking location, and procedure and location for storage of smoking materials. Focus- has an ADL self-care performance deficit and requires cues, setup, and/or assistance with ADLs r/t Stroke; Interventions: SIT TO LYING: Resident's usual performance is DEPENDENT /MAXIMAL ASSISTANCE - Helper does more than half effort. Helper lifts or holds trunk or limbs and provides more than half the effort. BED MOBILITY: The resident is totally dependent on (X2) staff for repositioning and turning in bed, as necessary. TRANSFER: The resident requires Mechanical Lift with (X2) staff assistance for transfers. Record review of CR #44's Discharge MDS dated [DATE] revealed, discharged Status- deceased . Record review of CR #44's Visual/Bedside Kardex Report dated [DATE] revealed, the resident required: substantial/maximal assistance using a wheelchair; totally dependent for chair/bed to chair transfers; mechanical lift with 2 staff assistance for transfers; total dependence on 2 staff for repositioning and turning in bed as necessary; dependent/maximal assistance to go from lying to sitting on side of bed; dependent/maximal assistance to roll left and right in bed. Record review of CR #44's Clinical Assessments revealed, the last clinical assessment documented was on [DATE]. No clinical assessments were completed after the fire. Record review of CR #44's Progress Notes revealed,- [DATE] 09:30 PM signed by LVN I, At 9:30 PM the CNA and another CNA put resident to bed with the mechanical lift. Resident tolerated well.- [DATE] 01:54 AM signed by the DON, After speaking with the charge nurse and CNA, I called the RP's family member to inform her that CR #44 was involved in a fire incident and that she was being treated for possible burns. Explained that the ambulance was working on her at this time, and they would probably take her to the [Hospital]. The RP said she was not in town and that she would call her to see if he was closer than she was. RP said she would leave where she was and head to [Hospital] to check on CR #44.- [DATE] 08:03 AM signed by LVN I, At approximately 01:00 AM the writer was on hall 600 to check on the other resident in my care. On my way back to 400, as I was walking down the hall I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 27 of 46 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 10/07/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some observed residents in bed sleeping including room [ROOM NUMBER]. As the writer was at the back of the hall 400, approximately 10 minutes later the writer heard alarm sound with flashing lights. I heard a CNA calling me and telling me the fire was in room [ROOM NUMBER]. As the writer was going to room [ROOM NUMBER], the CNA who was in front of me, grabbed the extinguisher and entered the room before I got there. When I entered the room I said to the CNA to call 911, then I assisted the CNA to evacuate the room-mate while the other 2 CNA's was trying to put the fire out. Once the roommate was safely evacuated, I immediately went to render aide to [CR #44]. As I was getting ready to assess the resident 911 was already here and in the room. The EMT's asked where the other resident was, and I told them she was outside. EMT's were providing medical care to [CR #44] and I left the room to go be with the residents that were outside. I then notified the DON once the residents were evacuated off of the hall and accounted for.[DATE] 10:21 AM signed by MA C, resident expired. An observation on [DATE] at 09:58 AM revealed, CR #44's room floor covered by white powder and the room had been cleared of contents. There were gloves and packs of Personal Cleaning Wipes on the floor and on the bed. An off-white metal bed lie closest to the entrance, with no mattress and visible black fire damage. The center of the headboard was warped and melted with black burn marks, black ash/soot was observed on the base of the headboard, bed frame, and on the floor. There was limited evidence of smoke damage on the walls and ceiling with wipe marks on the ceiling directly above CR #44's bed and an imprint caused by smoke on the wall where something was hung that was now removed. In an interview on [DATE] at 03:31 PM, the Medical Director said she had been Medical Director in the facility for the last 1 1/2 to 2 years. She said if a resident had extensive burns, the facility would not initially treat the burns while in an emergency situation but would cover the resident with clean, dry sheets; monitor breathing and keep the resident warm after the fire was extinguished. She said a resident with severe burns would need specialized treatment that only the hospital could provide but she would expect nursing facility staff to assess the residents signs, mainly the breathing. The Medical Director said to maintain a residents life prior to arrival of EMS, staff must monitor vital signs and monitor alertness. Once the resident was moved away from the fire source, staff should make sure the airway is clear, resident is breathing, provide oxygen if necessary, monitor the residents pulse and blood pressure until EMS arrive. The Medical Director said if assessments and aid is not rendered and the resident had severe burn the resident could go into shock and a lot of things could happen. She said a resident with severe burns to the upper chest with shallow breathing should not be left unattended and someone should be with a resident if they have severe burns. The Medical Director said nursing home staff can provide services to help sustain life until EMS arrives and the resident should be continuously monitored. In an interview on [DATE] at 04:15 PM, the DON said when an individual experienced extensive burns they must be immediately assessed. Bleeding should be stopped, the airway must be assessed for lung sounds, and vitals assessed. She said nursing staff must stay with the resident until help arrived, and part of the competency of a nurse is training on how to react in an emergency situation. The DON said prior to the fire on [DATE] staff were not trained on what do to if a resident had a severe burn, but they know what to do now. She said to her knowledge nursing staff did not assess CR #44 after the fire was extinguished. The DON said no one assessed CR #44 after the fire but they should have as it was a professional standard. When asked about the risk to residents if staff failed to assess them following extensive burns., The DON said based on her investigation, she thought CR #44 was expired when she was found on fire and no one told her the resident was moving and groaning at the time of the fire. She said, only god has the power over life and death, and if a resident expired it was in God's Hands. When pressed the DON said treatment rendered to a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 28 of 46 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 10/07/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some resident with extensive burns was based on what the assessments yields, but staff should make sure the resident was breathing. In an interview on [DATE] at 03:25 PM, the ME said CR #44's cause of death was still pending but the resident suffered from 2nd (burn that damages the top layer of skin and part of the 2nd layer) and 3rd (burn that destroys the first three layers of skin and the fatty tissue) degree burns on her head, upper torso and extremities. She had significant charring (severe burn that has destroyed all layers of skin and ,ay extend into underlying tissue caused by prolonged exposure to extreme heat that appears black or ash-gray) especially to the left side of her body not the right. There was soot deposition in her airway/bronchi, which indicated she was breathing while on fire. 26% of CR #44's body surface was burned. Resident #2 Record review of Resident #2's Face Sheet dated [DATE], revealed a 93- year- old female who admitted to the facility on [DATE] with diagnosis which included: Type 2 diabetes, COPD, dementia, epilepsy (brain disorder with recurrent, unprovoked seizures), and Irregular heartbeat. Record review of Resident #2's admission MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 0 out of 15. The resident had lower extremity functional limitations in range of motion used automobile chair and required maximum assistance for most ADL's. For mobility, the resident was either dependent or required maximum assistance. The resident was fully dependent on staff to propel in a motorized wheelchair for 50 to 150 feet. Record review of Resident #2's undated Care Plan revealed, Focus- Requires a wander guard bracelet and is at risk for injury fromwandering in an unsafe environment; Interventions: Monitor resident in facility and document attempts to elope out of facility. Focus: ADL self-care performance deficit r/t impaired cognition, poor safety awareness. Ambulates without use of an assistive device. She will at times hold onto the rails in hallway. Resident may require increased assistance with transfers depending on level of surface she is transferring from. Interventions: requires assistance of one staff to turn and reposition in bed at regular intervals. Record review of Resident #2's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- Resident #2 requires assistance of 1 staff to turn and reposition in bed at regular intervals and as necessary; requires assistance with lying to sitting at times. Transfer- requires assistance of one staff for supervision to move between surfaces as tolerated. Resident # 2 May require assistance with sit to stand if sitting for prolonged period of time or level of surface. Resident #3 Record review of Resident #3's Face Sheet dated [DATE] revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, paralysis following a stroke, dementia, anxiety disorder, and bed confinement status. Record review of Resident #3's Quarterly MDS dated 9/11 25 revealed, severely impaired cognition skills for daily decision making and impairments in functional limitations in range of motion for both sides of her upper and lower extremity. Record review of Resident #3's undated Care Plan revealed, Focus-Resident received oxygen as needed. The shortness of breath. Interventions: Monitor for signs and symptoms of respiratory distress- SOB, dyspnea (difficulty or labored breathing), low O2, cyanosis (bluish discoloration of skin indicating poor blood oxygen and circulation), diaphoresis (sweating), changes in behavior. Record review of Resident #3's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- total dependence on staff for repositioning and turning in bed. Lying to Sitting on side of bed: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Roll Left and Right: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to lying: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Sit to stand: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transferring: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 29 of 46 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 10/07/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Toilet transfer: dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Transfer: total dependence on staff for transfer. An observation on [DATE] at 10:19 AM revealed, Resident #3 lying in bed with eyes closed, well-dressed well-groomed in no immediate distress. Resident #6 Record review of Resident #6's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis (weakness and paralysis), type 2 diabetes, difficulty swallowing, dementia, and anorexia. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The use of a manual wheelchair, total dependence on most ADL's, and total dependence for most functional abilities. Record review of Resident #6's undated Care Plan revealed, Focus: Impaired visual function; Interventions: notify where you are placing their items. Be consistent and cater to the resident's preference of item placement. Focus: ADL self-care performance deficit, requires staff assist with ADL cares, refused to get out of bed daily; Interventions: Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of Hoyer lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of lift Record review of Resident #6's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility: extensive assistance to total assistance with 1-2 staff to turn and reposition in bed. Transfer: 2 staff to move between surfaces with use of lift. Transfers- requires total assistance x 2 staff to move between surface, transfers with use of lift An observation on [DATE] at 10:20 AM revealed, Resident #6 well dressed, well-groomed lying in bed awake. The resident responded to the surveyor with head nods and indicated she needed help. Resident #11 Record review of Resident #11's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophrenia, bipolar disorder, diabetes and hypertension. Record review of Resident #11's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 9 out of 15, one sided upper extremity and 2-sided lower extremity functional limitations in range of motion. Use of a wheelchair, total dependence with most ADLs and all functional abilities, total dependence for use of a manual scooter. Record review of Resident #11's undated Care Plan revealed, ADL self-care performance deficit and requires maximum assistance with ADLs r/t activity intolerance, Alzheimer's, impaired balance and limited mobility Record review of Resident #11's Visual/Bedside Kardex Report dated [DATE] revealed, Bed Mobility- lying to sitting on side of the bed- dependent helper does all the effort; roll left and right- substantial/maximal assistance helper does more than half of the effort. Sit to standdependent helper does all the effort. Transferring: Chair/Bed-to-chair Transfer- dependent, helper does all the effort and the assistance of 2 or more is required for the resident to complete the activity. Resident #18 Record review of Resident #18's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Parkinsonism, epilepsy, hypertension, difficulty breathing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, Short term and long term memory OK. And independent cognitive skills for daily decision making. The use of a wheelchair, no upper or lower extremity functional limitations in range of motion, substantial or maximum assistance to total dependence for all ADL's and substantial maximum assistance to total dependence on staff for mobility. Record review of Resident #18's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues,setup, and/or assistance with ADLs r/t Parkinson's Disease. Interventions: chair/bed-to-chair transfer: Resident's usual performance isdependent - Helper does all of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 30 of 46 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 10/07/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Lying to sitting on side of bed: resident's usual performance ispartial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Roll left and right: resident's usual performance is dependent - Helper does all of the effort. Resident does none of the effort to complete the activity. Sit to lying: Resident's usual performance is partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis which included: Alzheimer's disease, dementia and Major depressive disorder. Record review of Resident #20's Quarterly MSDS dated [DATE] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary. Transfer: supervision by staff to move between surfaces. Resident #36 Record review of Resident #36's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: dementia, generalized weakness, obesity, hip implant and altered mental status. The Resident's Code Status was do not resuscitate. Record review of Resident #36's Significant Change MDS dated [DATE], short-term and long-term memory problems, severely impaired cognitive skills for daily decision making, no upper and lower extremity functional limitations in range of motion, use of a wheelchair, and substantial/maximum assist with most self-care and all mobility. Resident #43 Record review of Resident #43's Face Sheet dated [DATE] revealed, a 72- year- old female who admitted to the facility on [DATE] with diagnosis which included COPD, bipolar disorder, and depression. Record review of Resident #43's Quarterly MDS dated [DATE] revealed, short and long term memory OK, moderately impaired cognitive skills for daily decision making, no behaviors, use of wheelchair with no upper or lower extremity functional limitations and range of motion and total dependence for self-care and mobility. Record review of Resident #43's undated Care Plan revealed, Focus: ADL self-care performance deficit r/t chronic pain,bipolar disorder and anxiety, has a specialized w/c; Intervention: bed mobility- total assist of one staff to turn and reposition in bed at regular intervals and as necessary. Transfer: totally dependent on 2 staff for transferring with a mechanical lift. Focus: Mobility and/or Assistive Device(s) Utilized by Resident: manual wheelchair. Resident #48 Record review of Resident #48's Face Sheet dated [DATE] revealed, a Three- year- old female who admitted to the facility with diagnosis, which included difficulty swallowing, memory deficit, major depressive disorder, generalized anxiety disorder, hypertension, left dominant side hemiplegia and hemiparesis following a stroke, Record review of Resident #48's Quarterly MDS dated [DATE] revealed, Severely impaired cognition as indicated by a BIMS score of 0 out of 10, upper and lower extremity functional limitations in range of motion on one side, total dependence for self-care and substantial to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 31 of 46 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 10/07/2025 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 - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete maximum assistance for most mobility. Total dependence for mobility with manual wheelchair for 50- 150 feet. Record review of Resident #48's undated Care Plan revealed, Focus: a self-care performance deficit r/t requires extensiveto total assistance r/t dementia, late effects of CVA, aphasia, bedbound, incontinence; Interventions: locomotion: utilizes a wheelchair when for proper positioning r/t impaired sitting balance and poor trunk control. Extensive assistance by one-two staff to turn and reposition in bed and wheelchair. Lift and extensive assistance by two staff to transfer at all time. Resident #54 Record review of Resident #54's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: Quadriplegia (paralysis that affects all limbs), anxiety disorder, weakness, and difficulty swallowing. The residents advanced directive was full code. Record review of Resident #54's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 8 out of 15, use of a wheelchair, upper and lower body, total dependence for all self-care, mobility, and quadriplegia. Record review of Resident #54's undated Care Plan revealed, focus: full code; interventions: appropriate care within guidelines of advanced directives; should [resident #54] be found with no pulse, respirations, or blood pressure, start CPR & call 9-1-1 immediately. Focus: ADL self-care performance deficit and requires cues setup, and/or assistance with ADLs r/t quadriplegia; interventions: usual performance is dependent - helper does all of the effort. [resident #54] does none of the effort to complete the activity or the assistance of 2 or more is required for [resident #54] to complete the activity. lying to sitting on side of bed: [resident #54]'s usual performance is dependent - helper does all of the effort. [resident #54] does none of the effort to complete the activity or the assistance of 2 or more is required for Event ID: Facility ID: 675543 If continuation sheet Page 32 of 46 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 10/07/2025 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 administer Parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #24) residents reviewed for parenteral fluids. - The facility failed to follow physician orders for Resident #24 to receive an oncologist evaluation for the removal of her implanted central venous access (port) for 58 days after the order was given on 07/23/25. On 09/19/25 the facility scheduled Resident #24 for evaluation by her oncologist on 10/07/25. This failure could place residents at risk of unwanted infections, hospitalization and further decrease in quality of life. Findings include: Resident #24 Record review of Resident #24's Face Sheet dated 10/02/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: left sided paralysis after a stroke, insomnia (difficulty sleeping), depression, anxiety, stomach bleed, repeated falls and lung cancer. An implanted port was not documented in her diagnosis. Record review of Resident #24's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 03 out of 15, upper and lower body functional limitations in range of motion, maximal assistance with most ADLs and maximum assistance with the use of a manual wheelchair. Active Diagnoses of: Cancer, hypertension, high cholesterol, one sided paralysis, anxiety and depression. Record review of Resident #24's undated Care Plan revealed, Focus: potential for skin tear of the r/t limited mobility. Focus: The resident is on pain medication therapy -ACETAMENIPHEN-CODEINE, LIDOCAINE; Interventions: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness. Focus: chronic pain on lidocaine,acetaminophen codeine; Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Focus: enhanced barrier precautions r/t indwelling medical device; Interventions: ENHANCED BARRIER PRECAUTIONS is necessary during high-contact care: Dressing; Bathing; Transferring; Providing hygiene; Changing linens, Changing briefs or assisting with toileting; Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes; Wound care: any skin opening requiring a dressing. Her care plan did not specify the indwelling medical device was a port. Record review of Resident #24's Order Summary Report revealed,- 07/18/25 Enhanced Barrier Precautions ( infection control interventions designed to reduced the spread of MDRO) due to indwelling medical device to right upper chest dated 07/18/25.- 07/18/25 Central line dressing change-Catheter to the Right Upper Chest - Change sterile transparent dressing (or sterile gauze)to insertion site Q Weekly and PRN if wet, soiled, or not intact. as needed Change transparent dressing PRN when wet.- 07/21/25 Central line dressing change-Catheter to the Right Upper Chest - Change sterile transparent dressing (or sterile gauze) to insertion site Q Weekly and PRN if wet, soiled, or not intact. every day shift every Mon. Discontinued 09/10/25- 07/23/25 needs oncology follow up related to port removal to right chest.Record review of Resident #24's Progress Notes from 05/20/25 to 09/19/25- there was no documentation of communication to Resident #24's RP from admission to 09/17/25 in regards to the implanted port, its use, maintenance, adverse reactions or removal.- 09/19/2025 12:40 PM signed by the DON, While auditing the chart noticed an order from 7/23/25 from MD A requesting for the resident to follow up with Oncology for port removal. After speaking with the nurse, it was told that the family did not want the port removed. Spoke with NP A to discuss the order and if she still wanted to follow up. NP A said yes, because every time she speaks to [Resident #24] she complains of pain to the port site. Called the RP and educated him on the port and what the NP said about his [Resident #24] experiencing pain related to the port. The RP said if Resident #24 wants the port Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 33 of 46 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 10/07/2025 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some out, then we need to take it out. Educated Resident #24 on what the said. The RP was not able to give me information about who the Oncologist was. Called the caregiver who was able to give the writer the information. The caregiver said, they did not want the port removed because they thought Resident #24 was still going to get cancer treatments. Explained to the caregiver what the said and the caregiver was in agreement. The caregiver gave the writer for the follow-up appointment. Writer was able to obtain an appointment for October 7, 2025. Record review of Resident #24's Physician Order dated 09/19/25 revealed, follow up with oncologist for port removal. An observation and interview on 09/29/25 at 11:07 AM revealed, Resident #24 lying in bed in no immediate distress. She said she was all right but her chest was bothering her. She said it hurt to turn her arm because the tube in her (implanted port) caused her discomfort and she wanted it removed. Resident #24 said she wanted a walker because her implanted port hurt when she used a wheelchair. An observation and interview on 10/02/25 at 12:40 PM revealed, Resident #24 was well-dressed, well-groomed in no immediate distress sitting in a wheelchair in her room. Resident #24 said her port was giving her hell, and it hurt whenever she wheeled herself in her wheelchair and the port goes up and down. She didn't say her port hurt when she was not using her wheelchair, but it let her know it is there. Resident #24 said Acetaminophen controlled her pain and the facility was working with the doctor to get her port taken out. Her implanted port was observed as circular raised area on her right chest, with loss of pigment. Her skin was intact with no redness, [NAME] or drainage observed. In an interview on 10/06/25 at 10:10 AM, the DON said she did not know what happened between the order received in July but in September when she found the missed order she took immediate action and got her an appointment for October. She said she didn't see any action/notifications following the physicians orders and failure to follow physician order to assess a port with no care could place residents at risk of infection. In an interview on 10/06/25 at 10:29 AM, RP #1 said prior to September the facility had not notified him of the discomfort Resident #24 experienced due to her port. He said he had no issues with the port being removed and it was up to him and he provided the facility the information of her oncologist. In an interview on 10/06/25 at 10:39 AM, Resident #24's family member said September 2025 was the first time the facility notified any of the residents family that her physician recommended removal of her port and that it caused her discomfort. In an interview on 10/06/25 at 11:09 AM, NP A said the facility scheduled an appointment in September with Resident #24's Oncologist to evaluate removal of the resident's implanted port since she was no longer using it for chemotherapy. NP A said prior to September Resident #24 had an infection on her foot so she could not undergo surgery to remove the port, but she did not have any concerns for the port because it was an implanted devices, and the facility was not accessing it. NP A said evaluation of Resident #24's port site and labs indicated no signs and symptoms of infection. She said the facility did not have the ability to remove the port and required an Oncologist to evaluate. In an interview on 10/06/25 at 11:27 AM, the ADON said if a resident arrived to the facility nursing staff must investigate if the port should be removed or will continue to be used. She said a port must be maintained with flushes to make sure they continue to work and the presence of a port could place residents at risk of infection and if they become colonized they make an infection harder to fight and could result in sepsis. The ADON said nursing staff are expected to follow up on the need of any kind of port. She said she was not responsible for infection control when the resident arrived at the facility and the DON was responsible to ensure the port was assessed by the oncologist but she took maternity leave. The ADON said to her knowledge nothing had been done about the physicians order to remove Resident #24's port, and there was no reason she had not had her evaluation by an oncologist. In an interview on 10/06/25 at 11:47 PM, LVN E said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 34 of 46 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 10/07/2025 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete sometimes worked with Resident #24. She said the resident had not complained about pain or discomfort due to the port. In an interview on 10/06/25 at 12:52 PM, RN B said Resident #24 had not reported any pain or discomfort associated with the port In an interview on 10/07/25 at 10:12 AM, the ADON said she started her position as the Infection Preventionist at the end of August of 2025. She said it was her responsibility to monitor all venous access devices. Since a port is indwelling it should be monitored to check for apparent signs of trauma. The ADON said a resident that admits with an implanted port should have orders in place when they arrive. She said she monitored residents with lines/ports upon admission or once treatment is initiated in the facility for their use and when the antibiotic is finished or the port is no longer in use she initiates orders with their provider to remove the device. The ADON said prior to September she was unaware Resident #24 had a port so she was not following her and could not initiate orders to remove her port. In an interview of 10/06/25 at 02:47 PM, the DON said the failure to remove Resident #24 port could place resident at risk for infection. Record review of the facility policy titled Infection Preventionist with no revision date revealed, Policy: The facility will employ one or more qualified infection prevention and control program. There was no information addressing implantable device monitoring. Event ID: Facility ID: 675543 If continuation sheet Page 35 of 46 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 10/07/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure nurses were able to demonstrate competency in skills to provide nursing and related services for 1 of 1 resident (Resident #1) by 1 of 2 nurses (LVN G) reviewed for competent staff, in that: The facility failed to ensure LVN G was competent to administer medications and knowledgeable regarding Enhanced Barrier Precautions. This failure could place residents at complications from g-tube medication administration or possible infection risk. Findings included:Record review of Resident #1's face sheet dated 10/3/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction (disorder when blood flow to a part of the brain is blocked leaking to lack of oxygen and nutrients) and Gastrostomy Status (surgical opening in the abdominal wall). Record review of Resident #1's quarterly MDS dated [DATE] revealed BIMS could not be conducted. Section K revealed Resident #1 had a feeding tube while a resident. Record review of Resident #1's Order Summary Report dated 10/3/25 revealed GT: Enhanced Barrier Precautions (the targeted use of gowns and gloves during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms) due to the presence of G-Tube with order date of 8/19/25.Record review of Resident #1's Care Plan printed 10/3/25 revealed Resident #1 was on enhanced barrier precautions related to indwelling medical device of PEG tube. Care Plan also revealed a focus that Resident #1 will receive all nutrition and hydration via feeding tube with intervention to administer medications as ordered. During observation on 10/3/25 at 10:08 a.m., LVN G administered medications to Resident #1 individually through his g-tube. LVN G poured water in the medication cups just prior to administering each medication and slightly agitated the cup to mix by picking the medication up and moving it in a circular motion for a few seconds. Significant residue was observed in the medication cups that was used for Sennoside, Vitamin C, Thiamine and One Daily Multivitamin after administration to Resident #1. Metoprolol was crushed and was at bedside but was not administered as LVN G was unable to check Resident #1's blood pressure as the blood pressure cuff had low battery.Observation on 10/3/25 at 10:15 a.m. revealed LVN G threw the medication cup with the crushed Metoprolol that was not administered in the trashcan in the resident's room. During interview and observation on 10/3/25 at 10:16 a.m., LVN G said medications were supposed to be disposed of in the sharp's container which was located on the medication cart. LVN G said she was unsure if she could take the medication out of the room since the resident was on precautions. LVN G said she was unsure if she could take the Metoprolol out of the room since the resident was on precautions. LVN G said Resident #1 was on standard precautions and then said she was not sure what precautions Resident #1 was on. Enhanced Barrier Precautions sign on the doorway near the residents' name was visible during the interview. When LVN G was asked what Enhanced Barrier Precautions was, she said I don't know. When LVN G was asked how she normally kept the medications from having residue in the medication cups, LVN G said she crushed all the medications and put them in a large cup and mixed with water so there was normally no residue left. LVN G said normally she would put all the medications in one cup but wanted to do the right thing. During interview on 10/3/25 at 11:32 a.m., LVN G said she had worked at the facility for about a month. LVN G said she had no training regarding g-tube administration in orientation at the facility. LVN G said she shadowed a nurse and then the nurse shadowed her once she was on the floor. LVN G said she was observed giving g-tube medications during the shadowing time. LVN G said the nurse she shadowed administered all the g-tube mediations together. LVN G did not know the last name of the nurse who shadowed her but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 36 of 46 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 10/07/2025 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete gave the first name as the same as the first name of RN B. During interview on 10/3/25 at 11:39 a.m., the Regional Nurse Consultant said he offered the facility proficiency checks and would be observing LVN G performing g-tube administration. During interview on 10/3/25 at 2:41 p.m., the DON said the nurses get a competency check off for g-tube administration. The DON said the Consultant Pharmacist and the Regional Nurse Consultant walked with a nurse until they were proficient. The DON said the Regional Nurse found two or three people to observe for medication administration which could include g-tube administration and was at the facility weekly. The DON said the Consultant Pharmacist came to the facility monthly and went with the nurses, which could include g-tube administration. The DON said it was her goal to do more of a finalized training since she had only been at the facility for six weeks. During interview on 10/3/25 at 3:31 p.m., the Consultant Pharmacist said if there were nurses in need of any type of observation the facility could ask her to watch the nurse or medication aide for medication pass and denied any issues with observation of g-tube medication administration in the past. The Consultant Pharmacist said medications should be given individually when given through a g-tube. The Consultant Pharmacist said you want to make sure the medications were well dissolved, and the cup was rinsed as the resident might not get the entire dose if there was residual left in the medication cup when administering medications. During interview on 10/3/25 at 3:42 p.m., RN B said they administered medications separately though a g-tube after being mixed with 10-15 cc of water and said she had not precepted anyone since she had been at the facility . During interview on 10/4/25 at 12:26 p.m., the DON said she was unable to find training records for LVN G. The DON said she did not know how records were kept prior to her arrival, which was six weeks ago but she had put a binder together once she arrived. The DON said the records have been stored in the DON's office and she had been gathering the training documents. The DON said nurses new to the facility train with another nurse for three days . The DON said LVN G had trained with a nurse who was no longer at the facility and gave a different first name from RN B who still worked at the facility. The DON said if a nurse needed more time, then we always give it and work with them. The DON said she would provide the training records for LVN G if she found them. The DON said the effect it could have on the residents if there were no training records for staff was the nurse should be proficient and competent as they have been licensed by the board. During interview on 10/4/25 at 1:27 p.m., the Corporate Director of Compliance said there was not a policy regarding nurse competency when a policy regarding nurse competency or training was requested. In an interview on 10/06/25 at 01:40 PM, the DON said the facility never assessed LVN G's competency for administration of medication via G-tube. She said the consultant pharmacist was supposed to assess her prior to the medication error on 10/03/25 but it didn't happen because LVN G said she would only perform oral medication administration. Record review of LVN G's employee records revealed, she was a PRN staff and her date of hire was 09/02/25.Record review of facility's policy Enhanced Barrier Precautions dated 2025 revealed all staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. Record review of facility's policy Medication Administration via Enteral Tube dated 2023 revealed Each medication will be administered separately, not combined or added to an enteral feeding formula. Event ID: Facility ID: 675543 If continuation sheet Page 37 of 46 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 10/07/2025 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Number of residents sampled: Number of residents cited: Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to update the facility nursing postings on 09/29/25, 10/03/25 and 10/04/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: An observation on 09/29/25 at 10:16 AM revealed, the facility Daily Staffing Report posting located on the top of the counter at the central nursing station that read 09/24/25. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM). The posting indicated the facility census, staff types (RN, Wound Care, LVN/LPN, CNA, Shower tech, CMA and RN Admin) and hours worked for both shifts. An observation on 10/03/25 at 02:54 PM revealed, the facility Daily Staffing Report posting located on the top of the counter at the central nursing station that read 10/03/25. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM). The posting indicated the facility census, staff types (RN, Wound Care, LVN/LPN, CNA, Shower tech, CMA and RN Admin) and hours worked for both shifts. An observation on 10/04/25 at 08:22 AM revealed, the facility Daily Staffing Report posting located on the top of the counter at the central nursing station that read 10/03/25. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM). The posting indicated the facility census, staff types (RN, Wound Care, LVN/LPN, CNA, Shower tech, CMA and RN Admin) and hours worked for both shifts. In an interview on 10/06/25 at 02:47 PM, the DON said she was responsible for the facility nurse staffing posting. She said the posting had to include the date, census, facility staffing and the quantity of each staff type and its purpose was to let everyone know the staffing for that day. The DON said she updated the posting Monday- Friday and prepared Saturday and Sundays for the weekend supervisor to uncover on each day. She said the posting is normally updated when she comes in at 9 AM, and failure to update the posting will leave people unaware of how much staff they have in the building. The DON denied failing to update the posting. Record review of the facility policy titled Nurse Staffing Posting Information revised 03/2025 revealed, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 38 of 46 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 10/07/2025 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 9% based on 4 errors out of 43 opportunities, which involved 1 of 1 resident (Resident #1) and 1 of 2 staff (LVN G) observed during medication administration reviewed for medication error.The facility failed to ensure Resident #1 received the complete doses of:1. Multivitamin Oral Tablet2. Sennosides-Docusate Sodium Oral Tablet 8.6-50 mg3. Vitamin C 500 mg4. Thiamine HCL Oral Tablet 100 mgThe failure could place residents at risk of not receiving therapeutic dosages and/or effects of medications. Findings included:Record review of Resident #1's face sheet dated 10/3/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction (disorder when blood flow to a part of the brain is blocked leaking to lack of oxygen and nutrients) and Gastrostomy Status (surgical opening in the abdominal wall). Record review of Resident #1's quarterly MDS dated [DATE] revealed BIMS could not be conducted. Section K revealed Resident #1 had a feeding tube while a resident. Record review of Resident #1's Order Summary Report with active orders as of 10/3/25 revealed physicians orders for Multivitamin Oral Tablet with instructions to give 1 tablet via G-Tube one time a day for wound healing, Sennosides-Docusate Sodium Oral Tablet 8.6-50 mg with instructions to give 1 tablet via G-Tube one time a day for constipation, Thiamine HCL Oral Tablet 100 mg with instructions to give 1 tablet via G-Tube one time a day for dietary supplement and Vitamin C 500 mg with instructions to give 1 tablet via G-Tube two times a day for wound healing. Record review of Resident #1's Care Plan printed 10/3/25 revealed Resident #1 was on enhanced barrier precautions (the targeted use of gowns and gloves during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms) related to indwelling medical device of PEG tube. Care Plan also revealed a focus that Resident #1 will receive all nutrition and hydration via feeding tube with intervention to administer medications as ordered. During observation on 10/3/25 at 10:08 a.m., LVN G administered medications to Resident #1 individually through his g-tube. LVN G poured water in the medication cups just prior to administering each medication and slightly agitated the cup to mix by picking the medication up and moving it in a circular motion for a few seconds. Significant residue was observed in the medication cups after administration to Resident #1 that was used for Sennoside, Vitamin C, Thiamine and One Daily Multivitamin. During interview on 10/3/25 at 10:22 a.m., the DON said LVN G was new to the facility. The DON said the Consultant Pharmacist was in the building this morning and she had asked the Consultant Pharmacist to work with LVN G. During interview on 10/3/25 at 11:32 a.m., LVN G said the effect it could have on the resident if there was residual left in the medication cup after administering medication would be the resident would not be getting all the medication they needed. LVN G said she had worked at the facility for about a month. LVN G said she had no training regarding g-tube administration in orientation at the facility. LVN G said she shadowed a nurse and then the nurse shadowed her once she was on the floor. LVN G said she was observed giving g-tube medications during the shadowing time. LVN G said the nurse she shadowed administered all the g-tube mediations together. LVN G did not know the last name of the nurse who shadowed her but gave the first name as the same as the first name of RN B. During interview on 10/3/25 at 11:39 a.m., the Regional Nurse Consultant said he offered the facility proficiency checks and would be observing LVN G performing g-tube administration. During interview on 10/3/25 at 2:41 p.m., the DON said the effect on a resident if residual was left in the medication cup when administering medication was that the resident was not getting all of the medication, so the medication was Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 39 of 46 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 10/07/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete not effective. During interview on 10/3/25 at 3:31 p.m., the Consultant Pharmacist said if there were nurses in need of any type of observation the facility could ask her to watch the nurse or medication aide for medication pass and denied any issues with observation of g-tube medication administration in the past. The Consultant Pharmacist said medications should be given individually when given through a g-tube. The Consultant Pharmacist said you want to make sure the medications were well dissolved, and the cup was rinsed as the resident might not get the entire dose if there was residual left in the medication cup when administering medications. Record review of the facility's policy Medication Administration dated 2024 revealed the six rights of medication administration are followed which includes the right dosage and crushed medications are not to be combined and given all at once, if via feeding tube. Event ID: Facility ID: 675543 If continuation sheet Page 40 of 46 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 10/07/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured and locked in accordance with currently accepted professional principles during medication administration of 1 of 2 staff (LVN G).The facility failed to ensure that LVN G did not throw Resident #1's crushed Metoprolol in the trashcan in the resident's room.This failure could place residents at risk of obtaining medications that were not ordered for them and potential adverse reactions or side effects. Findings included:Record review of Resident #1's face sheet dated 10/3/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction (disorder when blood flow to a part of the brain is blocked leaking to lack of oxygen and nutrients) and Gastrostomy Status (surgical opening in the abdominal wall). Record review of Resident #1's quarterly MDS dated [DATE] revealed BIMS could not be conducted. Record review of Resident #1's Order Summary Report dated 10/3/25 revealed Metoprolol Tartrate Oral Tablet 25 mg with instructions to give 1 tablet via G-tube one time a day with order and start date of 8/19/25. Observation on 10/3/25 at 9:32 a.m. revealed LVN G crushed Resident #1's Metoprolol Tartrate Oral Tablet 25 mg and placed in an individual cup.Observation on 10/3/25 at 10:01 a.m. revealed LVN G attempted to check Resident #1's blood pressure but was unable as the blood pressure cuff had low battery. LVN G said she would give Resident #1's Metoprolol later after administering the rest of Resident #1's medications she had ready when she was able to obtain a working blood pressure cuff. Observation on 10/3/25 at 10:15 a.m. revealed LVN G threw the medication cup with the crushed Metoprolol in the trashcan in the resident's room. During interview on 10/3/25 at 10:16 a.m., LVN G said medications were supposed to be disposed of in the sharp's container which was located on the medication cart. LVN G said she was unsure if she could take the medication out of the room since the resident was on precautions. LVN G said an effect of disposing medications in the trash can in the resident's room could have on residents was someone could pick it up or notice it. During interview on 10/3/25 at 3:31 p.m., the Consultant Pharmacist said if a medication was opened but not given, she recommended the medication to be placed in the sharps container so potentially no one could reach in and take it out. The Consultant Pharmacist said the effect it could have on a resident if a medication was thrown away into a resident's trash can was there was a concern that someone could take it out of the trash can. Record review of facility's policy Destruction of Unused Drugs dated 2023 revealed drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. Event ID: Facility ID: 675543 If continuation sheet Page 41 of 46 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 10/07/2025 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 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. 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 provide diagnostic services to meet the needs of its residents in a timely manner for 1 of 1 (Resident #1) residents review for radiology services. - The facility failed to ensure a chest x-ray was performed timely for Resident #1 following his physicians order given to rule out pneumonia on 10/01/25. The chest x-ray was performed on 10/06/25. This failure could place residents at risk of delayed diagnosis and medical treatment to prevent complications and injuries. Findings Included: Resident #1 Record review of Resident #1's Face Sheet dated 10/02/25 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: left side paralysis, aphasia (inability to speak) after a stroke (interruption of blood flow to the brain that causes tissue damage), difficulty swallowing, anxiety disorder, gastrostomy ( a tube passed through the abdomen into the stomach used for food or medication administration), and pneumonia (infection of the lungs). Record review of Resident #1's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, upper and lower extremity functional limitations in range of motion, total dependence for most ADLs and use of a feeding tube. Record review of Resident #1's undated Care Plan revealed, Focus: responsible party requests full code status; Goal- resident's wishes will be honored on an ongoing basis; Interventions: Monitor for decline in change of condition-report to M.D. and responsible party. Record review of Resident #1's Physician Progress Note dated 10/01/25 at 08:00 AM signed by MD A revealed, Chief Complaint: Cough with congestion; Audible cough with congestion noted with diminished breath sounds on exam. Resident #1 remains on room air without signs of respiratory distress. Chest V-ray ordered continues on tube feeds. Diagnostics Tests- chest X-ray ordered, Record review of Resident #1's Order Entry dated 10/01/25 revealed, Description: CXR to evaluate cough. The order was entered by MD A on 10/01/25 at 03:03 PM and confirmed by RN B on 10/01/25 at 4:32 PM. Record review of Resident #1's Progress Notes dated 10/01/25 to 10/07/25 revealed:- No evidence of follow up or X-ray completion from 10/01/25 to 10/05/25.- 10/06/25 at 02:43 PM, CXR order from 10/1 re-entered MD A called to notify. Radiology Company was notified and CXR has been completed.- 10/06/25 at 03:49 PM, Respiratory assessment completed. Pulse Ox 97% (the measure of oxygen carried in the blood) on room air no cough noted at this time. Resp effort and rate WNL. Relaxed and regular. Rhythm regular 18 resp per min lung sounds clear throughout. Resident sitting in bed with HOB 45 degrees. No distress noted.- 10/06/25 at 11:45 PM, Chest X-Ray 2 views results: No evidence of acute cardiopulmonary disease. Stable when compared to prior exam. Result send to NP for review. No new orders. Responsible party at bedside and was notified. Record review of Resident #1's Radiology Results Report dated 10/06/25 at 06:20 PM revealed, PROCEDURE: Chest Xray; INDICATION: Pneumonia; IMPRESSION: No evidence of acute cardiopulmonary (relating to the heart and the lungs) disease. An observation on 09/29/25 at 11:34 AM revealed, Resident #1 lying in bed receiving formula via his G-tube. The resident was nonresponsive to the surveyor but appeared to be in no immediate distress. His breathing appeared unlabored and he did not have a cough. An observation on 10/06/25 at 01:13 PM revealed, Resident #1 lying in bed receiving formula via his G-tube. The resident was non-responsive to the surveyor but appeared to be in no immediate distress. His breathing appeared unlabored, and he did not have a cough. In an interview on 10/06/25 at 01:18 PM, RN B said when a physician gave an order for an x-ray it must be documented in the 24 hour report. She said she was Resident #1's nurse, she had not observed him with a cough, she did not know there was a pending X-ray, she didn't know any orders were entered for Resident #1's CXR. RN B said there has been no communication to her, nursing, or the RP about the pending CXR. In an interview of 10/06/25 at 01:20 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 42 of 46 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 10/07/2025 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 0776 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete PM, the DON said when radiology orders were entered by a provider, nursing staff must then confirm the order. She said she didn't know why Resident #1's X-ray had not been taken yet, Resident #1's cough that required a CXR for further evaluation was considered a change in condition so all the notifications that should be sent out. The DON said RN B confirmed the order for Resident #1's CXR in the EMR system. In an interview of 10/06/25 at 02:47 PM, the DON said when staff received a physician order for radiology they must enter it into the EMR which is integrated with the laboratory and then document it in the progress note and in-house 24 hour report log. She said RN B failed to document the order and follow up with the x-ray and that is why it was missed. The DON said failure to timely complete radiology orders could place residents at risk for worsening of condition and delay in care. In an interview on 10/06/25 at 03:42 PM, MD A said when she assessed Resident #1 on 10/01/25 he was observed to have diminished lung sounds and a cough. The resident had been in and out of the hospital with pneumonia and received enteral feeds via a G-tube which put him at risk for aspiration pneumonia (pneumonia as a result of inhaling vomit) so she was concerned about the cough. She said older individuals like Resident #1 present differently from young, healthy people because their weak immune system can result in normal WBC (elevation indicative of infection), no fever, and since they can't mount the same immune response they end up with Walking Pneumonia. MD A said in individuals like Resident #1 she would order an X-ray to rule out pneumonia. She said normally when she entered CXR orders, it took radiology company a day perform the imaging and the facility would then call her to notify her of the results. MD A said she was not aware the facility had not completed the CXR order she entered on 10/01/25, a 5 day delay was not acceptable and the facility shouldn't drop the ball on things like this. She would not identify any risks associated with failure to implement radiology orders timely but said it would delay identification of an issue or fail to rule out a suspected concern. Record review of the facility policy titled Radiology and other Diagnostic Services and Reporting with no revision date revealed, Policy: The facility must provide or obtain radiology and other diagnostic services when ordered by a physician, physician assistant; nurse practitioner or clinical nurse specialist in accordance with state law. Policy Explanation and Compliance Guidelines: 1. The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. 3. All radiology and other diagnostic services will only be ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law, including scope of practice laws. Event ID: Facility ID: 675543 If continuation sheet Page 43 of 46 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 10/07/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 6 of 6 meals reviewed for food and nutrition services.The facility failed to ensure the menu was followed for the lunch and dinner meals on 10/02/25, 10/03/25, and 10/04/25. This failure placed the residents at risk of not receiving meals that are adequate to meet their nutritional needs and a decline in nutritional health status.The findings included:Review of the facility's weekly menu, entitled Senior Living S/S Southern 2024, Week 2, revealed the following menu plan:10/02/25 Lunch: Breaded catfish, potato wedges, creamy cole slaw, wheat bread, and [NAME] hash pie10/02/25 Dinner: Roasted red pepper soup, saltines, French dip sandwich, cottage cheese, and mixed melon salad.10/03/25 Lunch: Fried Chicken, okra, cornbread, brownie mousse bar.10/03/25 Dinner: Cheese Quesadilla, seasoned black beans, southwest slaw, apple slices.10/04/25 Lunch: Baked glazed ham, au gratin potatoes, Key [NAME] vegetable blend, wheat bread, banana cupcake10/04/25 Dinner: Unstuffed peppers, roll, orange wedges.Review of the Menu board posted outside of the dining room on 10/02/25 at 11:28 AM revealed the following:lunch menu for the day: bacon maple fish, potato wedges, coleslaw, pudding.dinner menu: homemade soup, cottage cheese, melon salad, corn bread. Everyday Menu listed Grill Cheese comes with soup and side salad, Hamburgers Basket comes with fries or chips, Sandwich of the day comes with fries, chips, or soup. There was no weekly menu posted. In an observation and interview on 10/02/2025 at 12:40 PM, Resident #53 received a hamburger from the Everyday Menu as requested but no side came with the hamburger. Resident #53 did not know why she did not receive a side with her hamburger. The posted Everyday Menu has comes with fries or chips for the Hamburger Basket, which Resident #53 had ordered.In an interview on 10/03/25 at 9:30 AM Resident #53 reported she was offered broccoli cheese soup and cornbread for dinner the previous evening, 10/02/25. She declined the soup and ate cornbread with milk. She ate in her room and did not see what other residents were offered.In an interview on 10/03/2025 at 10:36 AM with the Dietary Director, she reported they served a vegetable soup with hamburger meat, cornbread, a sandwich, and the cottage cheese and melons for dinner on 10/02/25. She reported that the residents do not like roasted red pepper soup, so it was substituted for a soup with hamburger meat with vegetables because the meat makes it a more substantial meal with the protein. She reported all the changes were approved by the dietitian. They just had a quarterly meeting to review the menus with the dietitian. The menu in her office had red pen marks noting changes for each meal in the month. She said there would be a new menu coming with the changes. When asked for records of dietitian approval for menu changes, she was not able to produce any paperwork or documentation. The Dietary Director reported that the residents do not like the fancy food on the menu such as quesadillas and chicken parmesan. The residents prefer the southern cooking that reminds them of home. She also reported that she was unable to order the desserts listed on the menu due to the cost of the ingredients. The Brownie Mousse Bar was substituted for cake because they could not purchase ingredients like chocolate or purchase pre-prepared deserts like lemon cookies or tiramisu cake and stay within the budget. They make the deserts from scratch to save money. The menus are prepared by a new service provider to this facility. The menus were previously done by another company, but that contract was cancelled recently. They order food from the new vendor as well as getting the menus quarterly. She orders food by determining needs from her changed menu.In an interview on 10/03/25 at 12:22 PM the [NAME] who prepared the dinner on 10/02/25 reported there was not a sandwich served with the soup. The soup was broccoli cheddar. Grilled cheese sandwich was served as alternate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 44 of 46 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 10/07/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete meal. There was not a side served with the soup other than cottage cheese with fruit syrup on it. No fruit was served. The [NAME] reported that she cooks whatever the Dietary Director tells her is the meal. The menu is not posted in the kitchen.Review of the Menu board posted outside of the dining room on 10/03/25 at 10:06 AM revealed the following:lunch menu for the day: oven fried chicken, okra/tomato, rice, cornbread, cake with whipped topping.dinner menu: Enchiladas, southwest salad, black beans, apple slices.Review of the Menu board posted outside of the dining room on 10/04/25 at 11:26 AM revealed the following:lunch menu for the day: pork loin, au gratin potatoes, Malibu vegetable blend, rolls, chocolate chip cookies. dinner menu: Unstuffed peppers, green beans, bread, apple slices. In an interview on 10/06/25 at 12:08 PM with the Registered Dietitian for the facility, she revealed the approvals for changes of the weekly menu were made by the Regional Registered Dietitian and she had not approved any menu changes made by the Dietary Director.In an interview on 10/07/25 at 10:16 AM with the Regional Registered Dietitian, she reported the menu process is that the vendor sends out Spring and Summer menus. The facility started using them for menus in February of this year. She reported that they try to focus on residents' choices. They have a food committee of residents that meet and the upcoming menu is reviewed. The resident council can submit feedback on the meals as well. Their feedback is used in decision making to change menu items but they stay within the same nutritional value. The protein will stay the same and swap a vegetable for a vegetable. They have a substitution log that should be completed and signed off by the Registered Dietitian. She was not aware if there was a specific food committee at the facility. She reported they always have an alternate menu available. Residents should be offered what is on the printed menu or a substitute of equal nutritional value.In an interview on 10/07/25 at 12:26 PM with the Administrator, she reported she was not aware that the Dietary Director was not following the weekly printed menu and substitutions were being made without appropriate approval. She reported she will ensure the menus and meal preparations are carried out following the policies going forward.Record review of the facility policy, Menus and Adequate Nutrition, 2025 revision, revealed: Policy section titled Policy Explanation and Compliance Guidelines: 3. Menus shall be prepared at least two weeks in advance for timely approval and ordering of food. Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance. 4. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods with comparable nutritive value.8. The facility's dietitian or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus. Event ID: Facility ID: 675543 If continuation sheet Page 45 of 46 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 10/07/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #41) of 7 resident reviewed for infection control. The facility failed to ensure LVN C wore a gown while performing wound care for Resident #41. This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases. The findings included:Record review of Resident #41's face sheet dated 10/1/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (high blood sugar) with Foot Ulcer and Other Acute Osteomyelitis (the bone infection) of the Right Tibia and Fibula (bones of the lower leg). Record review of Resident #41's quarterly MDS dated [DATE] revealed a BIMS score of 8 that indicated moderate cognitive impairment.Record review of Resident #41's Order Summary Report dated 10/1/25 revealed Enhanced Barrier Precautions due to wound with order date of 6/19/2025.Record review of Resident #41's Care Plan Report printed 10/1/25 revealed Resident #41 was on enhanced barrier precautions consisting of gown and gloves and was necessary during high-contact care including wound care.Observation on 10/1/25 at 10:15 a.m. revealed LVN C did not wear a gown while providing wound care to Resident #41 who was on enhanced barrier precautions. Observation also revealed Enhanced Barrier Precautions sign was at door of Resident #41's room. During interview on 10/1/25 at 10:42 a.m., Resident #41 said the staff usually wore a yellow gown when they performed wound care. During interview on 10/1/25 at 10:43 a.m., LVN C said she forgot to wear the yellow gown. LVN C said she normally wore a gown when providing wound care. When LVN C was asked why she forgot to wear a gown during wound care she replied everything that went on today as it had been reported that LVN C had a wreck on her way into the facility that morning. During interview on 10/2/25 at 2:14 p.m. with the ADON said Enhanced Barrier Precautions was used for a resident when they have any hole that was artificial like an open wound that required a dressing. The ADON said staff needed to wear a gown and gloves if they were providing hands on care. The ADON said if a staff member provided wound care to a resident on Enhanced Barrier Precautions and did not wear a gown that it could possibly open a portal to infection and a wound was a possibility of introducing bacteria, so it was a way for the resident to get an infection. The ADON was also the Infection Preventionist. Record review of facility's policy Enhanced Barrier Precautions dated 2025 revealed PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and high contact resident care activities included wound care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675543 If continuation sheet Page 46 of 46