Health inspection·July 2, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Sunday and Monday to work the floor. She said laundry might not have enough people working to keep linen clean and readily available. In an interview with the Administrator on 6/27/24 at 12:17pm he said he must admit there was an issue with linen. He said the company he used was in a different State and have issues with supply since they had a fire or some type of disaster. He said he had made an order on 6/24/2024 for linen, towels and had ordered 5 dozen or more, but they had not been delivered. He said they had not received the order from April as far as he can recall. He said clearly there was not enough linen, and he had asked staff to get rid of badly stained sheets, but he should have waited until his order came in. He said he can only recall one resident with a grievance about stained sheets. He said the residents in room [ROOM NUMBER] had scoop mattresses and they do not put sheets on them. He said he did not have a central supply staff and he and the DON was ordering linen. In an interview on 6/27/24 at 1:55pm with Maintenance Director,/Housekeeping and Laundry supervisor, employed here for 2 years. He said it was a puzzle as to what was going on with linen. He said he believed that (CNAs) were hiding them and throwing them away. He said he did a linen sweep and found linen hidden in resident drawers. He said he admited having flat sheets and towels available are an ongoing issue. He said their linen were stored on the cart located on each hall. He said they did not have any additional storage of linen. He said they currently had linen in the dryer. He said the Administrator ordered more linen this week. He stated he has 8 staff members that he supervised. He stated he normally worked 8a-5pm and on-call every day. Maintenance Director/Housekeeping and laundry supervisor He said his staff schedules were: Laundry- 5a-1p, 6a-2p and 1p-9p or 12p-9p shifts. He said they did their last laundry load at 9pm. however staff have complaint of having no linen sometimes when he arrived at work at 8am in the morning. He said CNAs are there usually in at 7am and they have all the linen that they have on-hand available on the carts. An interview on 6/28/2024 at 10:38am, Regional Nurse said the facility normally ordered linen through a company in California. She said they are looking at getting linen, towels, diapers, wipes and gloves from a local vendor. She said she did speak with the Administrator and mentioned that the facility should have sets of linen in the wash, in storage and sets that are ready to go for each resident. She said the Administrator will work on this and get more linen and supplies in this week. An interview on 6//28/2024 at 12:46pm, a resident RP, said she talked to the Administrator about supplies in general. Diapers and wipes are always low. She said she brought in diapers for the resident. She said the linen have had holes and are badly stained. She said last week sometimes she came to visit, and the resident had linens that were stained and the blanket as well with urine and/or feces. She said she was very upset and complained to the Administrator. She said staff had to find a gown for the resident and she was told they were waiting on linens to come from laundry. She said the facility had no emergency or backup linens available. An interview on 6/28/24 at 1:04pm, Laundry Aide B she said there was simply not enough linen in the building. She said they do not have gowns or sheets for residents. She stated she had been employed at the facility since 2005. She said some of the sheets were thrown away and she got them out of the trash. She said she normally worked 11:30am-7pm. She said they had gray barrels used for linen a few months ago but now she was picking up laundry with a grocery basket. She said clean linen was placed in the hallway carts. She said, there is just not enough linen in the building. She said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 2 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0584 Level of Harm - Minimal harm or potential for actual harm linens they have were filled with holes and badly stained. She said they wash linen all day and still can not keep up with the demand for linen. Review of linen policy was requested but there was no policy concerning linen was provided prior to exit. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 3 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #1) of six residents observed for pleasure feedings. Residents Affected - Some The facility failed to ensure that Resident #1's received pleasure feeding as ordered by the physician. These failures could place residents at risk for weight loss and further decline in health status. Findings included: Resident #1 Record review of Resident #1's admission face sheet revealed he was [AGE] year-old male that was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included volvulus (twisting or knotting of the gastrointestinal tract), constipation (difficult having a bowel movement), vascular disorder of mail genital organs (disorder that affect the blood flow of the penis), unspecified protein calorie malnutrition (lack of protein and calories to meet nutritional need), cerebral palsy(abnormal brain development that affect muscle control) and gastrostomy (a surgical procedure where a tube is inserted in the stomach for feeding). Record review of Resident #1's quarterly MDS dated [DATE] revealed for cognition the resident was severely impaired, incontinent of bowel and bladder, total care for activities of daily living and was fed via a feeding tube. In an interview with a family member on 7/2/2024 at 4:00pm revealed that there was an order for Resident#1 to be fed by mouth and the facility was not feeding him. The family member felt this was due to inadequate staffing. Record review of Resident #1's physician's order dated 04/10/2024 revealed an order for the patient to have a modified barium swallow study to be done. On 04/15/2024 revealed result of MBSS to be okay and recommend that the resident could eat by mouth. Record review of the physician's order dated 5/13/2024 for patient allowed pleasure feeds of puree textures upon family request. No liquids at the time, patient refusal. Prior to PO intake, have patient seated upright. Observation on 7/2/2024 revealed Resident #1 in bed with fall mat at bed side. Feeding tube infusing Jevity 1.5 at 50ml per hour and water at 30ml per hour. Resident #1's call light was observed to be in reached. Clothes clean and resident was dry. Observation on 7/2/2024 of Resident #1 during lunch meal revealed no meal tray was given to resident #1 for pleasure feeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 4 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0658 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's nurse progress notes dated between 5/13/2024 and 7/2/2024 revealed no documentation the Resident#1's was given a pleasure tray or had refused to eat. In an interview on 7/2/2024 at 4:20pm CNA E said Resident #1 was fed via a feeding tube. CNA E said she worked with Resident #1 sometimes and had never seen a tray for the resident. Residents Affected - Some In an interview on 7/2/2024 at 4:22pm CNA D said Resident #1 was fed via a feeding tube and he had never seen him fed by mouth. CNA D said he worked with Resident #1 and had never seen a tray for the resident. In an interview with the DON on 7/2/2024 at 5:00pm she said the order was per family request and it was not clear. She said she did not call the doctor to clarify the order and did not know if anyone else did. Record review of the undated facility policy regarding 0ral Medication Administration did not address dietary requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 5 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, based on the comprehensive assessment of a resident, 1 resident (Resident #3) of 3 residents reviewed for pressure sores received the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. Residents Affected - Few 1-Resident #3 had a large pressure sore that was not properly dressed. 2-The Charge Nurse and Treatment Nurse were not aware that the dressing was not on the wound. 3-The facility had no documentation of measurements of the pressure sore since admission. The failure placed this resident at risk for worsening of the pressure ulcer and/or possible infection. Findings included: Record review of the admission Record (copied 07/02/24) for Resident #3 reflected she was [AGE] years old, and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, pressure ulcer of the sacral region, pressure induced deep tissue injury of the right heel, and persistent vegetative state (all diagnoses upon admission). Record review of the MDS admission assessment dated [DATE] reflected Resident #3 was admitted from a short-term medical hospital. The MDS reflected she was dependent for repositioning. Record review of the Care Plan for Resident #3 dated 06/24/24 reflected she had a pressure wound and was at risk for additional skin breakdown, infection, and worsening of the present wound. One intervention was reflected as .Perform treatment per order . Record review of the Braden Scale for Predicting Pressure Ulcer Risk dated 06/14/24 reflected a score of 13 (Moderate Risk). Record review of Resident #3's hospital record reflected the sacrum pressure sore was a stage 4, and was measured at 15 cm x 15 cm x 5 cm. Observation and interview on 07/02/24 at 10:12 a.m. revealed Resident #3 was lying on her bed. The Wound Care Nurse (WCN) and CNA A were in the room. The resident had bilateral heel protectors on. WCN and CNA A tilted Resident #3 to the left. The dressing on her right heel was dated 06/27/24. WCN verbally confirmed the date. Resident #3 was turned onto her left side. The sacral wound was packed with gauze. There was no dressing covering the wound. There was no loose dressing visible in the brief or linens. WCN verbally confirmed there was no dressing on the wound. CNA A said he had not provided care for Resident #3 this morning. In an interview on 07/02/24 at 10:14 a.m. LVN C, the hall Charge Nurse, said no one had informed her that Resident #3's sacrum did not have a dressing on it. She said LVN D provided wound care on 07/01/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 6 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 07/02/24 at 10:30 a.m. revealed WCN provided wound care, assisted by CNA A. When Resident #3 was tuned onto her left side, the sacral wound was observed. There was packing visible in the wound, but no dressing to secure it or protect it from contamination. There was scant bloody drainage. WCN removed the packing. There were no concerns with technique. Continued observation and interview revealed WCN provided wound care for Resident #3's right heel. He removed the dressing dated 06/27/24. He said, That's one I did. There was a superficial open area on the right heel, approximately 3 cm diameter. WCN provided wound care with no additional concerns. Record review of a Physician's Order dated 06/26/24 revealed Resident #3's sacrum wound was a Stage 4 pressure sore. The order was to clean the wound with normal saline or wound care cleaner, pat dry, apply Vashe wet-to-dry dressing, and cover with a foam dressing daily and as needed. Record review of a Physician's Order dated 06/26/24 revealed Resident #3's right heel was to be cleaned with normal saline or wound care cleaner, pat dry, apply skin prep, then cover with a dry dressing every Tuesday, Thursday, and Saturday, and as needed. The most recent scheduled date would have been 06/29/24. Record review of Resident #3's electronic record did not reveal any facility measurements of the sacral wound. In an interview on 07/02/24 at 1:50 p.m., the DON said the wound care nurse was responsible to ensure wound care was completed. If the wound care nurse was not present, the weekend nurse or an 'as needed' nurse would be responsible. She said if a dressing was missing, the CNA should report it to the nurse. She said a complication of not having a dressing on the wound would be deterioration. The surveyor informed the DON that he could not locate facility measurements of the sacrum wound in Resident #3's electronic chart. She said she would send them in an e-mail. As of 07/10/24 no email with measurements has been received by the surveyor . In an interview on 07/02/24 at 2:11 p.m., WCN said Resident #3's sacral wound should have been covered. There was an 'as needed' order to cover the wound as well. He said Resident #3 did not have a dressing on the wound when he observed it with the surveyor that morning. He said if the wound was not covered, feces or urine could get into the wound and cause infection. He said the nurse working on that hall would have been responsible to cover the wound if the dressing was missing. He said the CNA had not gotten to Resident #3 prior to the observation. He said Resident #3 was admitted to the facility with the wounds. Record review of the facility policy Wound Monitoring Guidelines (undated) revealed, in part, .A resident who has developed or is admitted with a wound (vascular, arterial, stasis, stalled/non-healing/stalled surgical sites, large complex skin care/other) will receive necessary treatment and services to promote healing, prevent infection and prevent new wounds from developing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 7 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 6 residents (Resident #1, Resident #2 and Resident #9) reviewed for sufficient staffing. -The facility failed to ensure there were sufficient staff per the facility assessment and failed to provide repositioning for Resident #1 and Resident. -The facility failed to provide Incontinent care to Residents #1 and Resident #2 and Resident #9. with bowel/bladder incontinence on 6/27/2024 and 6/28/2024. These failures could place residents at risk of their needs not being met, skin breakdown, and loss of dignity. Findings Included: Record review of the facility assessment tool dated April 2024 through April 2025 revealed Staffing plans is was based on your population and their needs for care and support, facility general approach to staffing to ensure that facility have sufficient staff to meet the needs of the residents at any given time include: The average daily census was 94 residents. The facility had 18 residents with behavioral needs, 11 residents required injections. Tracheostomy care 18 residents and ventilator or Respirator 7 residents. The facility residents break down of ADL care was 32 residents dependent on bathing, 30 residents dependent on bed mobility, 20 residents dependent on eating, 25 residents dependent on personal hygiene, 24 residents dependent on toilet use, 26 residents dependent on transfer. The average number suggested for licensed nurses providing direct care was 5 licensed nurses (Days & Evening), 4 licensed nurses (Nights). Nurse Aides was 7 CNAs on Days and Evenings, 2 Restorative CNA split shift, 7 CNA/CMAs (Days & Evenings), 8 CNAs on Nights. Record review of facility map revealed [NAME] zone 1 was room [ROOM NUMBER] through 112, Dove zone 2 was room [ROOM NUMBER] through 125, Flamingo zone 5 was rooms 126 through 137, Swan zone 6 was rooms 138 through 149, Southeast wing zone 11 was rooms 201 through 206, and southwest wing zone 12 was rooms 207 through 224. Record review of the facility resident roster dated 6/27/24 revealed [NAME] station rooms 101-112, revealed 18 residents, Dove station rooms 114-125 revealed 18 residents, Flamingo station rooms 126-137 revealed 19 residents, Swan station rooms 138-149 revealed 16 residents and South station rooms 201-224 revealed 31. Total census of 102. Resident #1 Record review of Resident #1's face sheet dated 6/27/24 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Volvulus (a loop of the intestine twist around itself), muscle wasting & atrophy (muscles that lose their nerve supply), hypokalemia (a high level of potassium in the blood) and unspecified intellectual disabilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 8 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0725 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's MDS dated [DATE] revealed section B0600- Speech clarity (2) no speech, B0800- Ability to understand others (3) Rarely understood. C0500- Brief interview of mental status (BIMS) was unscored. Section GG-Functional abilities and Goals indicated: C. Toileting was coded as (1)-dependent, toileting transfer (09) Coded not applicable. Section H0300- Urinary Continence (3) -Always incontinent. H0400- (3) Always incontinent. Residents Affected - Some Record review of Resident'1's care plan date initiated on 4/8/24 revealed Bowel and bladder incontinence and was at risk for skin breakdown and pressure wound formation. Goal: Resident #1 will remain clean, dry, odor free and dignity will be maintained over the next 30 days. Interventions: Check for incontinent episode during rounds, change promptly and apply a protective skin barrier. Observations of Resident #1 were made on the following dates and times: Observation on 6/27/2024 at 11:03am of Resident #1 , revealed there was an offensive urine/bowel odor in his room. He was observed to have no cover on him, and exposed diaper was bulgy in front with yellow stain. He was observed lying on his back. Observation on 6/27/2024 at 12:43pm, revealed Resident #1 still had the same diaper with yellow stain in front. He was observed lying on his back. Observation on 6/27/24 at 2:17pm, revealed Resident #1 still had the yellow stained diaper on. He was lying on his back. Observation on 6/28/2024 at 4:01pm, Resident #1 was observed lying on his back. Resident #2 Record review of Resident #2 face sheet dated 6/27/24 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] ad re-admitted [DATE] with diagnoses of Aphasia ( language disorder that affects how you communicate)following cerebral infarction(occurs due to disrupted blood flow to the brain), dysphagia (difficulty swallowing), cognitive deficit(impairment in one or more cerebral functions such as language, attention or memory), muscle weakness, need for assistance with ADL's. Record review of Resident #2's care plan dated 7/5/2023 and revised on 5/20/2024 Focus: Bowel and Bladder incontinence stated Resident #2 was incontinent is at risk for skin break down and pressure wound formation. Goal: Resident #2 will remain clean, dry, odor free and dignity will be maintained. Interventions: Check for incontinence episode during rounds change promptly and apply protective skin barrier. Record review of Resident #2 annual MDS dated [DATE] revealed Section C0500- Brief Summary Score was unscored. Section GG- Functional abilities and Goals revealed: C. Toileting hygiene (01)- Dependenthelper does all the effort. I. Personal hygiene (01)- Dependent. H0300- Urinary Continence (3) BowelAlways incontinent, H0400-(3) - Always incontinent Observations of Resident #2 were made on the following dates and times: Observations of Resident #2 on 6/27/2024 at 11:03am, there was an offensive urine/bowel odor in his room. He was observed to be lying on his right side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 9 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0725 Observation on 6/27/2024 at 12:43pm, revealed Resident #2 was still lying on his right side. Level of Harm - Minimal harm or potential for actual harm Observation on 6/27/24 at 2:17pm, revealed Resident #2 was lying on his right side. 6/28/2024 at 4:01pm, Resident #1 was observed lying on his back. Residents Affected - Some Resident #9 Record review of Resident #9's face sheet dated 6/28/24 revealed an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of other cranial cerebrospinal fluid leak (a leak that occurs in the skull), unspecified dementia ( dementia without a specific diagnosis), history of falling. Record review of Resident #9's care plan dated 6/26/24 revealed ADL functional deficits: Resident #7 i s incontinent of (bladder/bowel) and is at risk for skin break down and pressure wound formation. Goal: Resident #7 will remain clean, dry, odor free and dignity will be maintained. Intervention: Check for incontinence during rounds and apply a protective skin barrier. Re-assess for possible toileting programquarterly and PRN. Record review of Resident #9's MDS dated [DATE] Section C0500- revealed BIM summary score of 05, which indicated severe cognitive impairment. Section H0300- Bladder and Bowel revealed (2) Frequently incontinent. Bowel Continence (3) indicated always incontinent. Observations and interview revealed: Observations and interview on 6/28/24 at 2:24pm - revealed Resident #9 room had a urine odor. She was covered with a sheet but stated she was wet, and no one had been in the room to change her since early in the morning. She Resident #9 could not recall the time she was last changed. Observation on 6/28/24 at 3:52pm, revealed her sheets were drenched with urine. Observed CNA D changing her sheets and with revealed urine stains and odor. An interview on 6/27/2024 at 11:14am, CNA A said he had been employed at the facility for 7 years. He said he was responsible for the care of 16-18 residents who resided on DOVE hall. He said there was 1 nurse and 1 medication aide that worked the Hall as well. He said in the course of his duties he was responsible for helping residents with ADL's, which included: showers and bed baths, dressing, and incontinent care. He said it was very difficult to keep up with all the assigned tasks on his hall. He denied not completing all resident care. He said it was difficult to finish everything. He said restorative aides were not available to help because they have their [NAME] hall to cover, and they have residents with high acuity on the South Hall such as dialysis patients. He said there were no shower aides that he was aware of. He said he had at least 2 total care residents on his hall. He named Resident #1, and Resident #2 as total care residents. He said all 18 residents on his hall needed some type of care. He said he did repositioning and incontinent care as a part of his job duties. An interview with 6/27/2024 at11:28am, LVN C stated she had been employed at the facility for a few months. She said the facility was currently running 1 CNA, 1 CMA and 1 nurse. She denied that they have shower aides. She said she normally work DOVE and SWAN halls. She stated it was hard on the CNAs to get everything done because there was usually only one on each hall. She said she help as much (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 10 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some as she could, but she had a lot of responsibilities too. She said was a floor nurse and she was responsible for G-tube, IV's, taking blood sugars, and applying creams. She said DOVE hall was considered a heavy acuity hall. She said there were at least 4 residents considered total care residents that require incontinent care, feeding, help with transfers, and showers. In an interview on 6/27/202 at 11:55am with Administrator revealed him to state he was running 5 CNA's plus two restoratives and shower aides to help. He stated that he was running a higher PPD (hours allotted per patient day) than the national average. He said he was currently utilizing a local staffing service when needed. He said he has tried to address all staffing concerns. He said he provided additional staff as requested by the DON. He said he was not aware that some residents were not receiving timely incontinent care or repositioning. He said the CNAs are responsible for providing incontinent care and he would follow-up with the DON. An Interview with Restorative Aide A at 6/27/24 at 12:00pm, she stated she had been employed at the facility for 2 years. She stated she does help change the residents as needed. She said today she was working as CNA on Flamingo Hall and only usually only have only 1 CNA per hall. She said she had 16 residents to provide care for. She said she was the only CNA working that hall. An interview with the DON on 6/27/24 at 12:30pm, she stated they are currently running North Hall nursing staff with (2 nurses, 2 med techs, and 5 to 6 CNA's) and South Halls has 3 nurses, and 2 to 3 CNA's. She said she was not aware of any incontinent care or repositioning not getting done due to the staffing that they were currently running. When asked about the acuity of the residents on Dove, she stated there were residents that have PICC tubes, 2-person assists and total care. She said CNA's and the nurses are responsible for resident care such as repositioning and incontinent care. She said she believe 1 CNA was adequate to care for residents down DOVE hall. She said they also have restorative aides that are floaters that can help. She said the Administrator determines if they have adequate staff and decided if agency will be used. She said they were constantly interviewing but they do not show up sometimes on the 1st day. She said they were running ads for CNA's and even offering an incentive upon hire. She said they have a lot of call outs as well that were last minute, and it makes it hard to get staff last minute. She said the floor nurses supervise CNAs. She said she also walks the facility looking for any care concerns. An interview with CNA B on 6/27/24 at 2:25pm, revealed she usually worked 7a-3p shift and DOVE hall was the normal hall she worked. She said she was responsible for showers, repositioning, incontinent care. She said she had changed Residents on DOVE hall every 2 hours. She said she was the only CNA working on the hall that day. She said it was very difficult to keep up with all the tasks needed for the residents. She said she had recently completed rounds and her residents' diapers were dry. She said 1 CNA on each hall was not enough to adequately care for residents. She said two residents on her hall were new and there was no time to build a rapport and learn their preference because there was always a rush to get things done. An interview with CNA D on 6/28/24 at 3:53pm revealed he had been employed at the facility for 2 months. He said he normally worked on DOVE hall on the 3pm-11pm shift. He stated Resident #7 diaper was wet, sheets and blanket. He said he just came on the shift at 3pm and was checking to see if Resident #9's brief needed to be changed . He said she was not changed on the previous shift obviously due to the entire bed bedding being wet. He said he was the only CNA working on that hall. He said they do not walk through with oncoming or staff leaving the shift to ensure residents care was completed prior to them leaving. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 11 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0725 Record review of undated job description for CNA revealed: Level of Harm - Minimal harm or potential for actual harm Reports to Director of Nursing Services Residents Affected - Some Summary: In keeping with our organization's goals, the primary purpose of the Certified Nursing Assistant is to deliver quality daily routine nursing care to resident's requiring short-term, skilled, and long-term nursing care, as directed by the supervisor. Responsibilities 1. Provide direct nursing care, under direct supervision/direction of a nurse, in accordance with federal and state regulations, facility policies and procedures, and prudent nursing judgment. 2. Report any observations and pertinent information, regarding resident care and condition, to the nursing supervisor promptly. 3. Document observations and care delivered to residents daily, per standards of practice and facility policy and procedures. Record review of staffing undated policy statement revealed-Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident needs and facility assessment. 2. Staffing numbers and the sills requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 12 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for of the 1 (Dove Hall) of 4 halls for residents who receive room trays from the facility's kitchen. Residents Affected - Some The facility did not maintain proper temperatures for room service trays for lunch on Dove hall. These failures could affect all residents who eat in their rooms and residents who received pureed meals by placing them at risk of weight loss, altered nutritional status and diminished quality of life. Findings included: Observation on 6/27/24 at 12:42pm, Dove hall food trays were in a warmer. Two plates observed inside that were covered with saran wrap. The food warmer was opened. There were no doors. In an interview on 6/27/2024 at 4:32pm, Resident #8 stated the food was cold and it was probably because his hall was served last every day. He said they do not have closed food warmer but the CNA's are serving them when they can. He said they only have one CNA on his hall, and this could be the issue why the food was cold. He said the Administrator knew about the food issue. In confidential interviews conducted with residents on 07/02/2024 at 9:30 a.m. the residents complained of cold foods on the hallway. They also said that they complained to the facility before, but they were still getting cold foods. One resident said that his room was to the back of the hallway, and he always get his meal last every day and his meal was always cold. Observation on 7/2/2024 at 1:05pm of the lunch hall tray cart revealed the cart was on the Dove halls for about 3 minutes before meal service began. The last hall trays was passed out at 1:10pm., at that time the test tray was taken off the cart to be tested for temperature, taste and palatability. The lunch test tray was done on 07/02/2024 between 1:10 p.m. and 1:15 p.m. with Dietary Manager and AIT to test for taste, temperature, flavor and palatability. The food temperatures were taken before the test taste began. The temperatures for the menu items were baked beans 110 F, beef brisket 97 F, cold potato salad 67 F, cold pureed potato salad 57.8 F, pureed beans 92.6 F and pureed meat 95.3 degrees F. The DM and AIT confirmed that food was tasty but it was cold. During an interview with DM on 7/02/2024 at 2:45 p.m. she said the food temperature was low because they did not have the hot covers on them. She said the temperatures were at the required holding temperature on the steam table. She said she was aware that the carts were not heated so they are planning to place orders for heated cart, plate warmers and Therma plate covers. She said thry will have to ensure that the menu items on the steam table were very hot and serve as quickly as possible to maintain the temperature until they get the warmer. In an interview on 7/02/2024 at 4:44 p.m. the Administrator said he was aware of the issues in the kitchen. He said he had discussed with the new Dietary Manager the issues regarding the cold foods and was looking into getting plate warmers and heated cart. He said he had heard about the cold foods before and had addressed it but did not know it was still an issue as he did not have any more (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 13 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0804 complaints regarding cold foods. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's undated Food Preparation and Service policy read in part . Residents Affected - Some Policy Statement: Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 14 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. (1) The facility failed to ensure food was labeled and dated. (2) The facility failed to ensure that equipment was cleaned. (3) The facility failed to ensure that the dish machine sanitizer was working properly. (4) The facility failed to ensure that staff were properly trained to do they duties. (5) The facility failed to ensure that food on the steam was at the correct holding temperature. (6) The facility failed to ensure staff maintained proper hygienic practices. (7) The facility failed to ensure refrigerator maintain 41 degrees or below. These failures could place residents who ate meals prepared by the kitchen at risk for food contamination and foodborne illness. Findings included: In an interview with Dietary Aide B on 6/27/24 at 11:35am, she said she had to do dishes with very little cleaning material. She said they usually purchase from Company A and that company had better dish washing products but now they are purchasing from another company and the dispenser does not work with that type of bottle top. She said she was concerned. She said when she used the chemical tester, and it did not turn purple. She said it was supposed to turn purple if it has the right amount chemical in it to ensure it was sanitizing as it should. The following interviews and observations were made during a kitchen tour on 07/02/24 that began at 10:00 AM and concluded at 10:45 AM: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 15 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0812 Liquid eggs in the cooler was not labeled or dated. Level of Harm - Minimal harm or potential for actual harm No thermometer was in the cooler and the thermometer on the outside cooler was 44 degrees . The stove back splash and the stove oven had an accumulation of burnt food particles and grease. Residents Affected - Some The oil in the fryer was black. In the dry storage room was had a disposable coffee cup with coffee in it and a disposable box with food. There was a bottle of pink liquid soap under a cart in the facility dry food storage room. Observation on 7/2/2024 at 10:30am of the dish machine during dish washing process revealed the thermometer temperature on the dish machine did not go above 90 degrees. The litmus paper did not change color when it was dipped in the water. Further observation revealed the sanitizer was not going through the tube to the dish machine. A closer examination of the bottle with the sanitizer revealed the lid with the tubing did not fit in the bottle and as a result the sanitizer was not going through the tubing. There was no fan to dish machine to facilitate air drying the dishes. Record review of the undated manufacturer operational requirements the dishmachine were wash temperature 120 gegrees F and rinse temperature was 120 degrees F minimum and required chlorine rinse was 50 ppm. In an interview on 7/2/2024 at 10:35am with Dietary Aide B she said the sanitizer was not going through the machine and the Administrator knew about it. She said the machine was a low temperature machine and needed the sanitizer to sanitize the dishes. She also said the machine was working when she was off and when she came back it was not working. She said the fan that dries the dishes after they came out of dish machine was taken down sometimes ago and it was not replaced. Observation on 07/02/2024 at 10:55am during the survey process revealed Staff O went to the trash can, open the lid of the can, and threw something in the trash can. She did not change her gloves nor wash her hands and she went back to making mashed potatoes. That was pointed out to the Administrator who instructed the staff to change her gloves, wash her hands and put on a pair of new gloves. In an interview with the Administrator on 7/2/2024 at 11:00am he said he was going to ensure the staff were trained on kitchen sanitation and handwashing and then have one and one training with them to determine understanding. He also said he was going to ensure that the kitchen was fully staff. He said the fan to the dish machine was taken off to be cleaned and as soon as it was clean it would be back up. He said they will be using disposables for lunch and was working on fixing the dish machine and rewashed the dishes. He said the temperture on the cooler could be due to the constant opening of the cooler. Observation of the steam table on 7/02/2024 at 12:20 pm revealed the following food temperatures were regular baked beans 136.4 F, potato salad 33.8 F, brisket 169 F, pureed brisket 140 F, pureed potato salad 39.3 F and pureed beans 130 degrees F. The pureed beans were reheated to above 165 degrees F. In an interview on 7/2/2024 at 1:35pm the Maintenance said he had taken down the fan to the Dish (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 16 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some machine about a week or so ago to clean it. He said he was new to the building and had not clean the fan at this building before. He said he was not aware of the sanitizer not working properly until that day. He said he fixed the sanitization issues and was going to work on cleaning the fan and putting it back up. In an interview with the DM on 7/2/2024 at 2:05pm she said moving forward she will have to ensure that she has a full staff that were trained. She said the kitchen staff needed training in all areas. She said sanitation procedures should be conducted correctly. She said residents could get sick because of the dietary sanitation and food temperature issues observed. Record review of the facility undated policy, Policies and Procedures titled Food Preparation, Cooking and Holding Temperatures and Times read in part . 1. The danger zone for food temperatures is between 41 F and 130 F . This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 F or above 130 F. Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) may cause foodborne illness. Record review of the facility undated policy, Policies and Procedures titled Food Receiving and Storage read in part . Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 1. Food Services, or other designated staff, will maintain clean food storage areas. 6. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 9. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. Record review of the facility undated policy, Policies and Procedures titled Dishwashing Machine Use read in part . Policy Statement Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 17 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0812 1. Level of Harm - Minimal harm or potential for actual harm The following guidelines will be followed when dishwashing: 2. Residents Affected - Some Dishwashing machine chemical sanitizer concentrations and contact times will be as follows with 120 degrees: Type of Solution Minimum Concentration Contact Time Chlorine 50-100 ppm 10 seconds Iodine 12.5 ppm 30 seconds Quaternary Ammonium 150-200 ppm Per manufacturer's instructions Record review of the facility undated policy, Policies and Procedures titled Refrigerators and Freezers read in part . Policy Statement This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation 1. Acceptable temperature ranges are 35°F to 40°F for refrigerators and 0°F or less for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 18 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0812 5. All food shall be appropriately dated to ensure proper rotation by expiration dates. Level of Harm - Minimal harm or potential for actual harm 6. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 19 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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 be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for 3 of 6 residents (Resident #1, Resident #2 and Resident #9 ) reviewed for facility administration in that: Residents Affected - Some -The facility Administrator and DON failed to ensure the facility had sufficient staff to ensure timely incontinent care and/or repositioning were provided for (Resident #1, Resident #2, and Resident #9). -The facility Administrator failed to ensure the facility had adequate linen, towels, briefs and wipes to care for the facility residents in a timely manner. -The facility DON failed to supervise CNAs to ensure they were providing timely incontinent care and repositioning as ordered. This failure could place all residents who were dependent on staff for ADL care at risk of having skin breakdown, infection, and loss of dignity. Findings included: Record review of the facility assessment tool dated April 2024 through April 2025 revealed Staffing plans was based on your population and their needs for care and support, facility general approach to staffing to ensure that facility have sufficient staff to meet the needs of the residents at any given time include: The average daily census was 94 residents. The facility had 18 residents with behavioral needs, 11 residents required injections. Tracheostomy care 18 residents and ventilator or Respirator 7 residents. The facility residents break down of ADL care was 32 residents dependent on bathing, 30 residents dependent on bed mobility, 20 residents dependent on eating, 25 residents dependent on personal hygiene, 24 residents dependent on toilet use, 26 residents dependent on transfer. The average number suggested for licensed nurses providing direct care was 5 licensed nurses (Days & Evening), 4 licensed nurses (Nights). Nurse Aides was 7 CNAs on Days and Evenings, 2 Restorative CNA split shift, 7 CNA/CMAs (Days & Evenings), 8 CNAs on Nights. Record review of facility map revealed [NAME] zone 1 was room [ROOM NUMBER] through 112, Dove zone 2 was room [ROOM NUMBER] through 125, Flamingo zone 5 was rooms 126 through 137, Swan zone 6 was rooms 138 through 149, Southeast wing zone 11 was rooms 201 through 206, and southwest wing zone 12 was rooms 207 through 224. Record review of the facility resident roster dated 6/27/24 revealed [NAME] station rooms 101-112, revealed 18 residents, Dove station rooms 114-125 revealed 18 residents, Flamingo station rooms 126-137 revealed 19 residents, Swan station rooms 138-149 revealed 16 residents and South station rooms 201-224 revealed 31. Total census of 102.Record review of Resident #1's faces sheet dated 6/27/24 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Volvulus (a loop of the intestine twist around itself), muscle wasting & atrophy (muscles that lose their nerve supply), hypokalemia (a high level of potassium in the blood) and unspecified intellectual disabilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 20 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0835 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's MDS dated [DATE] revealed section B0600- Speech clarity (2) no speech, B0800- Ability to understand others (3) Rarely understood. C0500- Brief interview of mental status (BIMS) was unscored. Section GG-Functional abilities and Goals indicated: C. Toileting was coded as (1)-dependent, toileting transfer (09) Coded not applicable. Section H0300- Urinary Continence (3) -Always incontinent. H0400- (3) Always incontinent. Residents Affected - Some Record review of Resident'1's care plan date initiated on 4/8/24 revealed Bowel and bladder incontinence and was at risk for skin breakdown and pressure wound formation. Goal: Resident #1 will remain clean, dry, odor free and dignity will be maintained over the next 30 days. Interventions: Check for incontinent episode during rounds, change promptly and apply a protective skin barrier. Observations of Resident #1 were made on the following dates and times: Observation on 6/27/2024 at 11:03am of Resident #1 , revealed there was an offensive urine/bowel odor in his room. He was observed to have no cover on him, and exposed diaper was bulgy in front with yellow stain. He was observed lying on his back. Observation on 6/27/2024 at 12:43pm, revealed Resident #1 still had the same diaper with yellow stain in front. He was observed lying on his back. Observation on 6/27/24 at 2:17pm, revealed Resident #1 still had the yellow stained diaper on. He was lying on his back. Observation on 6/28/2024 at 4:01pm, Resident #1 was observed lying on his back. Record review of Resident #2 face sheet dated 6/27/24 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses of Aphasia ( language disorder that affects how you communicate)following cerebral infarction(occurs due to disrupted blood flow to the brain), dysphagia (difficulty swallowing), cognitive deficit(impairment in one or more cerebral functions such as language, attention or memory), muscle weakness, need for assistance with ADL's. Record review of Resident #2's care plan dated 7/5/2023 and revised on 5/20/2024 reflected: Focus: Bowel and Bladder incontinence stated Resident #2 was incontinent was at risk for skin break down and pressure wound formation. Goal: Resident #2 will remain clean, dry, odor free and dignity will be maintained. Interventions: Check for incontinence episode during rounds change promptly and apply protective skin barrier. Record review of Resident #2 annual MDS dated [DATE] revealed Section C0500- Brief Summary Score was unscored. Section GG- Functional abilities and Goals revealed: C. Toileting hygiene (01)- Dependenthelper does all the effort. I. Personal hygiene (01)- Dependent. H0300- Urinary Continence (3) BowelAlways incontinent, H0400-(3) - Always incontinent Observations were made on the following dates and times: Observations of Resident #2 on 6/27/2024 at 11:03am revealed there was an urine/bowel odor in his room. He was observed to be lying on his right side. Observation on 6/27/2024 at 12:43pm, revealed Resident #2 was still lying on his right side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 21 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0835 Observation on 6/27/24 at 2:17pm, revealed Resident #2 was lying on his right side. Level of Harm - Minimal harm or potential for actual harm Observation on 6/28/2024 at 4:01pm, Resident #2 was observed lying on his back. Residents Affected - Some Record review of Resident #9's face sheet dated 6/28/24 reflected an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of other cranial cerebrospinal fluid leak (a leak that occurs in the skull), unspecified dementia (dementia without a specific diagnosis), history of falling. Record review of Resident #9's care plan dated 6/26/24 reflected ADL functional deficits: Resident #7 is incontinent of (bladder/bowel) and was at risk for skin break down a pressure wound formation. Goal: Resident #7 will remain clean, dry, odor free and dignity will be maintained. Intervention: Check for incontinence during rounds and apply a protective skin barrier. Re-assess for possible toileting programquarterly and PRN . Record review of Resident #9's MDS dated [DATE] reflected Section C0500- revealed BIM summary score of 05, which indicated severe cognitive impairment. Section H0300- Bladder and Bowel revealed (2) Frequently incontinent. Bowel Continence (3) indicated always incontinent. Observation and interview on 6/28/24 at 2:24pm revealed Resident #9 room had a urine odor. She was covered with a sheet but stated she was wet, and no one had been in the room to change her since early in that morning. She could not recall the time she was last changed. Observation on 6/28/24 at 3:52pm, revealed her sheets were drenched with urine. Observed CNA D changing her sheets and revealed urine stains and odor. An interview on 6/27/202 at 11:55am with Administrator revealed him to state he was running 5 CNA's plus two restoratives and shower aides to help. He stated that he was running a higher PPD (hours allotted per patient day) than the national average. He said he was currently utilizing a local staffing service when needed. He said he has tried to address all staffing concerns. He said he provided additional staff as requested by the DON. He said he was not aware that some residents were not receiving timely incontinent care or repositioning. He said the CNAs are responsible for providing incontinent care and he would follow-up with the DON. In a subsequent interview with the Administrator on 6/27/24 at 12:17pm he stated he must admit there was an issue with linen. He said the company he used was in a different State and have issues with supply since they had a fire or some type of disaster. He said he had made an order on 6/24/2024 for linen, towels and had ordered 5 dozen or more but they had not been delivered. He said they had not received the order from April as far as he can recall. He said clearly there was not enough linen, and he had asked staff to get rid of badly stained sheets, but he should have waited until his order came in first. He said he can only recall one resident with a grievance about stained sheets. He said residents in room [ROOM NUMBER] had scoop mattresses and they do not put sheets on them. He said he did not have a central supply staff and he and the DON were ordering linen. An interview with the DON on 6/27/24 at 12:30pm, she stated they were currently running North Hall nursing staff with (2 nurses, 2 med techs, and 5 to 6 CNA's) and South Halls has 3 nurses, and 2 to 3 CNA's. She said she was not aware of any incontinent care or repositioning not getting done due to the staffing that they are currently running. When asked about the acuity of the residents on Dove, she stated there were residents that have PICC tubes, 2-person assists and total care. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 22 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some CNA's and the nurses were responsible for resident care such as repositioning and incontinent care. She said she believe 1 CNA was adequate to care for residents down DOVE hall. She said they also have restorative aides that were floaters that can help. She said the Administrator determines if they have adequate staff and decided if agency will be used. She said they were constantly interviewing but they do not show up sometimes on the 1st day. She said they were running ads for CNA's and even offering an incentive upon hire. She said they have a lot of call outs as well that were last minute, and it makes it hard to get staff last minute. She said the floor nurses supervise CNAs. She said she also walks the facility looking for any care concerns. In an interview on 6/27/24 at 1:55pm with Maintenance Director/Housekeeping and laundry supervisor, employed here for 2 years. He said it was a puzzle as to what was going on with linen. He said he believed that they (CNAs) were hiding them and throwing them away. He said he had to do a linen sweep and found linen hidden in resident drawers. He said he admit not having flat sheets and towels were an ongoing issue. He said facility linen was stored on the cart located on each hall. He said they did not have any additional storage of linen. He said they currently had linen in the dryer. He said the ADM dministrator more linen this week. He stated he has 8 staff members that he supervised. He stated he normally worked 8a-5pm and on-call every day. He said his staff schedules were: Laundry- 5a-1p, 6a-2p and 1p-9p or 12p-9p shifts. He said they do their last laundry load at 9pm. But staff have complaints of no linen sometimes when he arrived at 8am. He said CNAs shifts were there usually at 7am and they have all the linen that they have on-hand available on the carts. An interview with CNA B on 6/27/24 at 2:25pm, revealed she usually work 7a-3p shift and DOVE hall was the normal hall she worked. She said she was responsible for resident showers, repositioning residents and incontinent care. She said she changed Residents on DOVE hall every 2 hours. She said she was the only CNA working on this hall (Dove Hall) today. She said it was very difficult to keep up with all the tasks needed for the residents. She said she had recently completed rounds and her residents' diapers were dry. She said 1 CNA on each hall was not enough to adequately care for residents. She said two residents on her hall were new and there was no time to build a rapport and learn their preference because there was always a rush to get things done. Observation and interview with Administrator and DON on 6/28/2024 at 9:29am, revealed there were 19 bags of medium sized briefs and 2 large bags of briefs. There were no XL briefs available. There were1 box of wipes which had 10- 48 count of wipes (total 480 wipes), and another box with 6 packages of re-closable wipe packs. The Administrator stated this was the only supply closet that housed briefs and wipes. He said he had placed an order and would have more briefs and wipes by tomorrow. He said it was important to have enough of brief and wipes to meet the needs of the residents. The Administrator stated he used a vendor that was not local for supplies, but he had emailed a local company to set up supply services with them. The DON stated this was the facility's only supply closet. She said more supplies had been ordered. She said the supplies were placed on the floor for use today and the 21 bags of briefs should be sufficed until their order arrived. She said there should be briefs and wipes on the carts located on all of the halls. An interview on 6//28/2024 at 12:46pm, a resident RP, stated she talked to the Administrator about supplies in general. Diapers and wipes were always low. She said she bought in diapers for the resident. She said the linen have had holes and were badly stained. She said last week sometimes she came to visit, and the resident had linen that was stained and blanket as well had urine and/or feces. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 23 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She said she was very upset and complained to the Administrator. She said staff had to find a gown for the resident and she was told they were waiting on linen to come from laundry. She said the facility had no emergency or backup linen available. An interview with CNA D on 6/28/24 at 3:53pm revealed he had been employed at the facility for 2 months. He said he normally worked on DOVE hall on the 3pm-11pm shift. He stated Resident #9's diaper was wet, sheets and blanket. He said he just came on the shift at 3pm and was checking to see if Resident #9's brief needed to be changed. He said she was not changed on the previous shift obviously due to the entire bed bedding being wet. He said he was the only CNA working on this hall. He said they do not do walk through with oncoming or staff leaving the shift to ensure residents care was completed prior to them leaving. Record review of the job description for DON revealed: Summary/Objective In keeping with our organization's goals, the primary purpose of the Director of Nursing is to plan, organize, develop and direct the overall operation of our Nursing Service Department. Success in this position is measured by compliance with current federal, state, and local standards, guidelines, and regulations that govern our facility. Additionally, success is measured through patient quality outcomes. 1. Assist the Administrator and/or the HR Director in the recruitment and selection of nursing service personnel. 2. Ensure that all nursing assistants have graduated from an approved training program. 3. Assign a sufficient number of licensed practical and/or registered nurses for each tour of duty to ensure that quality care is maintained. 4. Assign a sufficient number of certified nursing assistants for each tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident. 5. Develop work assignments and schedule duty hours, and/or assist nursing supervisory staff in completing and performing such tasks. Record review of Administrator job description revealed : Summary/Objective (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 24 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In keeping with our organization's goals, the Administrator is responsible for the oversight of all day to day functions of the facility. Success in this position is measured by compliance with all federal and local standards, guidelines, and regulations that govern nursing facilities. Additionally, success is measured through facility financial performance, patient outcomes, and risk mitigation. In collaboration with the Chief Operation Officer, this position is to observe, identify, correct, maintain, and develop processes and programs to ensure that the company's objectives are achieved. Management 1. Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the governing board 2. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. 3. Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures 4. Assist in recruitment and selection of competent department directors, supervisors, facility non-licensed staff, consultants, etc. 5. Counsel/discipline personnel as requested or as may become necessary 6. Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Record review of undated Administration policy revealed: A licensed Administrator is responsible for the day-to-day functions of the facility. Policy Interpretation and Implementation 1. The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 25 of 26 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 675557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis at Pearland 3400 E Walnut Pearland, TX 77581 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 0835 1. Level of Harm - Minimal harm or potential for actual harm Managing the day-to-day functions of the facility. 2. Residents Affected - Some Ensuring that each resident's right to fair and equitable treatment, self-determination, individuality, privacy, confidentiality of information, property, and civil rights, including the right to lodge a complaint. 3. Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities; In the absence of the Administrator, the Assistant Administrator or Director of Nursing Services is authorized to act in the Administrator's behalf. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675557 If continuation sheet Page 26 of 26