Inspection·April 12, 2023

F 0684 not toilet transfer, always incontinent of bowel and bladder, did not trigger for constipation, and no vomiting. Level of Harm - Immediate jeopardy to resident health or safety Record review of CR#1's Care Plan entry date 4/5/23 at 12:08 p.m. effective for 3/17/23 revealed CR#1 required assistance with ADL functions and the goal was to maintain a sense of dignity by being clean, dry, odor free, and well-groomed over next 90 days. Intervention: assist with ADL's as needed. CR#1 is prone to edema and is at risk for injury due to a decrease in ADL's CR#1 has edema .she takes diuretics. CR#1 will be able to maintain current ADL's and no injuries will occur over the next 90 days. CR#1 is on antibiotics and is at risk for adverse reactions. Goals: Infection will be resolved or resolving at the end of antibiotics therapy and CR#1 will not have any adverse reactions to the antibiotic therapy .Interventions: Monitor resident for adverse reactions specific to the medication, follow universal/standard precaution to prevent cross contamination and spread of infection, encourage fluid, and serve diet as ordered. CR#1 is incontinent of bowel and bladder. CR#1 requires extensive assistance with toileting. CR#1 will have toileting needs met with the assistance of 1-2 people next 90 days. Residents Affected - Few Record review of CR#1's Care plan entry date 4/5/23 at 12:08 p.m. effective for 3/17/23 revealed she was not care planned for constipation. Record review of CR#1's Physician Orders revealed: Amoxicillin 875 mg-potassium clavulanate 125 mg tablet 2 times daily for 7 days (antibiotic) 3/17/23 Doxycycline hyclate 100 mg capsule 2 times daily for 7 days (antibiotic) 3/17/23 Furosemide 40 mg tablet 2 times daily (diuretic) 3/17/23 Docusate sodium 100 mg tablet 2 times daily (stool softener) 3/23/23 Fleet enema 19 gram-7 gram/118 mL 1 time daily for 1 day 3/28/23 Lactulose 20 gram/30 mL oral solution PRN every 8 hours-3/28/23 Record review of CR#1's Medication Administration Record printed 4/6/23 revealed: Docusate sodium 100 mg tablet (1 tab) tablet oral two times daily starting 3/23/23 (constipation) 3/23-3/28/23 administered Fleet enema 19 gram-7 gram/118 mL (1) enema (ML) Rectal one time daily for one day starting 3/28/23 (constipation)-not shown as given on 3/28/23 and given on 3/29/23 Lactulose 20 gram/30 mL oral solution (1) solution, oral as needed every eight hours starting 3/27/23. Order date 3/28/23-nothing administered Record review of CR #1's ADL Verification Worksheet of meals dated 4/5/23 revealed: 3/17/23 Dinner 75% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 2 of 10 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 675663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Bend Healthcare Center 3010 Bamore Rd Rosenberg, TX 77471 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 3/18/23 Breakfast, lunch and dinner 100% Level of Harm - Immediate jeopardy to resident health or safety 3/19/23 Breakfast, lunch and dinner 100% Residents Affected - Few 3/21/23 Breakfast and lunch 100% and dinner 75% 3/20/23 Breakfast and lunch 100% and dinner 75% 3/22/23 Breakfast 75%, lunch 100% and dinner 75% 3/23/23 Breakfast and lunch 100% and dinner -nothing documented 3/24/23 Breakfast, lunch and dinner 100% 3/25/23 Breakfast and lunch 75% and dinner -not documented 3/26/23 Breakfast and lunch 100% and dinner 75% 3/27/23 Breakfast and lunch 75% and dinner - not documented 3/28/23 Breakfast and lunch 100% and dinner - not documented Record review of CR#1's ADL Verification Worksheet for Bowel Movements dated 4/5/23 revealed: 3/17/23 Bowel Movement 8:58 p.m. 3/18/23 Bowel Movement 8:36 a.m., and 2 p.m. 3/19/23 Bowel Movement 6:00 a.m. and 8:41 p.m. 3/20/23 Bowel Movement 9:05 a.m. and 3:26 p.m. 3/21/23 Bowel Movement 9:56 a.m. and 3:33 p.m. 3/22/23 Bowel Movement 9:09 a.m. 3/23/23 Bowel Movement 12:06 p.m. 3/24/23 Bowel Movement 8:47 a.m., 10:24 a.m. and 2 p.m. 3/25/23 Bowel Movement 8:05 a.m. 3/26/23 Bowel Movement 10:38 a.m. and 3:09 p.m. 3/27/23 Bowel Movement 10:42 a.m. 3/28/23 Bowel Movement 12:51 a.m. and 9:33 a.m. Record review of CR#1's SBAR Communication Form and Progress Note for RNs/LPN/LVNs dated 3/28/23 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 3 of 10 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 675663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Bend Healthcare Center 3010 Bamore Rd Rosenberg, TX 77471 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 - Few 5:17 p.m. written by LVN C revealed Before calling Physician/NP/PA/Other healthcare professional: Evaluate the resident .,check vital signs ., Review record: recent progress notes, labs, orders Situation: The change in condition, symptoms or [NAME] I am calling about is/are nausea/vomiting that started on 3/28/23. Since this stated has it gotten worse .This condition, symptom, or sign has occurred before: No .Background .Abdominal/GI/Evaluation: Abdominal tenderness, constipation, date of last BM 3/27/23, distended abdomen, nausea and/or vomiting .Previous complaints of constipation with emesis x 1 noted. NP contacted. New orders to be sent to local Hospital per family request for further evaluation. Record review of CR#1's Clinical Notes Report revealed ADON did not document 3/23/23 notes on CR#1's family member requesting to add docusate sodium to the MAR for constipation. Record review of CR#1's Clinical Notes Report written by LVN C dated 3/23/23 at 10:17 p.m. revealed, No complaints of pain or discomfort. Medicated as ordered. Record review of CR#1's Clinical Notes Report revealed there were no notes written regarding constipation from 3/17/23 to 3/26/23. Record review of CR#1's Clinical Notes Report written by LVN B dated 3/27/23 at 9:38 p.m. revealed Resident presents with abdomen distension, brown liquid emesis, complained of constipation, vital signs within normal limits. Notified NP gave new order to administer lactulose 30 mL now and daily PRN. No results also gave order for fleet enema. No results at this time. Will have oncoming Nurse to follow up. Record review of CR#1's Clinical Notes Report written by RN B dated 3/28/23 at 1:08 p.m. revealed She is incontinent of bowel and bladder. She has not requested anything for pain. She continues to be distended with slight bowel sounds and feels nauseous but not vomiting. She has a small amount of brown stool. Will continue to monitor . Record review of CR#1's Clinical Notes Report written by LVN C on 3/28/23 at 6:06 p.m. revealed, Resident complained of constipation with emesis x 1 noted. NP contacted. New orders to send patient out to hospital. Ambulance services called and patient sent to [local hospital] for further evaluation. [Family member] was visiting and present at time of transfer. Report called in to Nurse. Resident was picked up at 5:51 p.m. Record review of CR#1's Physician Progress Notes dated 3/28/23 at 9:34 p.m. revealed, .She is having gastric distention. She was nauseous, she threw up greenish-yellow bile a couple times. Absent bowel sounds all 4 quadrants. She is severely constipated as well. Vital signs are acceptable. Discussed the plan of care with her [family member] at bedside. We will go ahead and send her to ER for further evaluation and management of possible intestinal obstruction, severe constipation and/or UTI . Record review of CR #1's Local Hospital notes Emergency Medicine Provider Note dated 3/28/23 at 6:48 p.m. revealed, Patient presents from skilled nursing facility for abdominal distension, vomiting for the last 3 days, no bm for 3 days, abdominal pain-diffuse, acute for 3 days, no improvement with enemas with yellow vomit. Plan: severe sepsis, presumed intra-abdominal infection, sacral wound infection, acute pancreatitis, tachycardia, leukocytosis, elevated lactate. Meets severe sepsis criteria, pancreatitis, small bowel obstruction, and rectal impaction and ileus . Record review of CR#1's H&P by local Hospital Physician at 3/28/23 at 10:08 p.m. revealed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 4 of 10 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 675663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Bend Healthcare Center 3010 Bamore Rd Rosenberg, TX 77471 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 - Few .Subjective . Patients [family member] states that no bowel regimen was implemented while at SNF and she went many days without a bowel movement. Partly attributes constipation to the oral antibiotics, however also complained why no bowel regimen had been initiated while at SNF .Impression-1. Peripancreatic inflammatory changes and small amount of fluid extending, caudally along the paracolic gutters, right greater than left. Findings suggestive of acute pancreatitis. Correlation with serum lipase is visualized. No discrete drainable flexion. 2. Fatty infiltration of the liver. 3. Tiny bilateral pleural effusions. 4. Scattered air-fluid levels within proximal and mid small bowel, mildly dilated but without discrete point of transition favoring an ileus. 5. [NAME] type hernia involving the anterior wall of the proximal to mid transverse colon without associated inflammatory change or obstruction. 6. Large amount of stool within dilated rectum with mild rectal wall thickening suggesting fecal impaction. In an interview on 4/5/23 at 10:40 a.m. with CNA A she stated she worked the 6 a.m. to 2 p.m. shift and as a CNA she monitored eating, how many times the resident had a BM and documented in the computer. CNA stated she worked with CR#1 many times because she works the hall CR#1 was on. CNA A stated all her residents had been eating very well and there was no one that ate less than 25%. CNA A stated she did not know what happened to CR#1, but her family member came and was mad and not satisfied (unknown date). CNA A stated one morning on 3/27/23 CR#1 was throwing up and she was cleaning up and she notified RN A that morning and the family member. CNA A stated CR#1 only had pain when she was throwing up. CNA A stated CR#1 ate well and when she wanted to eat. She stated if CR#1 liked the food she ate it and fed herself. In an interview on 4/5/23 at 11:33 a.m. with the ADON, she stated CR#1 was admitted on [DATE] with sepsis and on 2 different antibiotics and CR#1's family member stated on 3/23/23 CR#1 was nauseated with the antibiotics. The ADON stated she did not hear back from CR#1's family member until the day CR#1 was discharged on 3/28/23 saying CR#1 was sick to her stomach due to the vitamin C and the zinc. The ADON stated on 3/23/23 CR#1's family member asked her why CR#1 was still on Lasix 80mg because CR#1 had no more edema on her legs. The ADON stated she called the NP, and he came to the facility after 3 p.m. and he spoke to CR#1's family member and the NP said to send CR#1 to the hospital. The ADON stated she did not hear CR#1, or the family member say CR#1 was constipated on 3/23/23, but CR#1 stated she was sick to her stomach on 3/27/23. The ADON stated that RN A said CR#1 was not constipated. The ADON stated the residents had water at bedside, and they checked on residents every 2 hours, but they do not monitor hydration. The ADON stated on 3/27/23 CR#1 had some distention, brown emesis and CR#1 complained of constipation on the night shift with RN B. The ADON stated the staff notified NP and he gave orders for lactulose daily and on 3/28/23 enema. The ADON stated CR#1 did not a BM when given the enema. She stated on the next shift CR#1 had a small amount of brown stool from the enema. In an interview on 4/5/23 at 12:46 p.m. with NP he stated that he saw CR#1 on 3/20/23 and she was an [AGE] year-old with lymphedema and recently came from hospital with weakness, edema, and cellulitis in both legs. The NP stated CR#1 had low grade fever and they ordered Augmentin for 7 days antibiotics and was acutely deconditioned and she was not walking because of leg and weakness. The NP stated CR#1 was alert and oriented x3. The NP stated he came again on 3/22/23 and saw her on wheelchair, and she said she did stand up with therapy and she was happy with her progress, and they discussed the goal is to make her feel better and increase level of functioning. NO obvious physical complaints. She denied any complaints. He stated on 3/27/23 he got a call saying CR#1 was constipated and he gave an order for lactulose and before that they gave her milk of magnesia. The NP stated CR#1's bowel did not move, and it was evening and there was no BM with the lactulose, so he gave an order for fleet enema that night and he did not get a call back. The NP stated the next day on 3/28/23 he went (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 5 of 10 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 675663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Bend Healthcare Center 3010 Bamore Rd Rosenberg, TX 77471 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 - Few to see CR#1 and he was told she had a BM that morning, but CR#1's family member was there, and he saw CR#1 was nauseous and throwing up. The NP stated CR#1 said yes, she had a BM but not enough. He stated CR#1's BM was very sluggish in listening to CR#1's bowel sounds, and she had a protruded abdomen accompanied by nausea and vomiting. The NP stated he suspected bowel obstruction; she may need bowel fluids and CR#1 may need suction through NG tube. The NP stated CR#1 needed gastric decompression that they can do in the facility, but they decided to send CR#1 to the hospital and the family member agreed with him to go to the ER. The NP stated CR#1 never did complain of constipation. The NP stated he would not have anticipated constipation and she did not have a diagnosis of constipation when she was admitted to the facility. In an interview on 4/5/23 at 1:03 p.m. with CNA A, she stated CR#1's BMs were not liquid, not big, she had regular small BM's. CNA A stated CR#1 never had a large BM, only small BM's, but CR#1 never said she was hurting. CNA A stated when she saw CR#1's family member on 3/28/23 she told her about CR#1 throwing up. CNA A stated CR#1 never had a big BM, but she did not see it as a problem because some residents go a little and some a lot. She stated if CR#1 would have said it hurt then she would have told the nurse. CNA A stated 3/28/23 was the first time she interacted with CR#1's family member and she told her to be careful because CR#1 had been throwing up and she had already notified RN A. In an interview on 4/5/23 at 1:28 p.m. with CNA B, she stated nothing was happening with CR#1, but that Sunday night (3/26/23) CR#1 said, baby my stomach hurt. CNA B stated she pulled the cover back and said, ooh her stomach is like a drum, and it was really hard. CNA B stated she worked with CR#1 all the time on the night shift when she was there. CNA B stated she worked 10 nights straight. CNA B stated she went to get RN B. CNA B stated CR#1 was wet and she said she will turn CR#1 on her side to see if CR#1 can push a poop out, and CR#1 did but it was not much. CNA B stated she left CR#1 on her side and came back, and CR#1 did not go. CNA B stated CR#1 stated she did not want to lay on her side, and she felt a little better. CNA B stated she put CR#1 back on her side again and she pushed a little more and a little more came out and CR#1's stomach was not as hard and that was the only night CR#1 complained she could not poop on 3/26/23. CNA B stated CR#1's poop was always small, but soft. CNA B stated she always paid attention to the stomach, but that was the first night her stomach was bloated out and hard. CNA B stated she worked from 9:45 p.m. to 6 a.m. In an observation and interview on 4/5/23 at 2:15 p.m. with CR#1 and CR#1's family member at a local hospital, she was observed to have an NG tube with IV fluids, fats, and antibiotics. CR#1's family member stated CR#1 was diagnosed with pancreatitis from the bowel obstruction. She stated the bowel obstruction was so bad that it caused pancreatitis and small bowel obstruction. CR#1's family member stated CR#1 has the NG tube in her nose going into the stomach and her stomach was so distended. CR #1's family member stated when she came to the facility CR#1 was vomiting dark green bile and the hospital put the NG tube to help relieve the stomach of whatever was in there. CR#1's family member stated CR#1 had not eaten in a couple of days, only ice chips. The family member stated CR#1 had been requesting soup because she could not eat and on Saturday, 3/25/23 they had soup and Sunday, 3/26/23 no food was given to the resident. CR#1's family member stated on Tuesday, 3/28/23 the staff came into CR#1's room fussing because CR#1 did not eat anything, and her tray was in the room. The family member stated the staff did not see her in the room initially, then she stated CR#1 must be full from breakfast, but CR#1 had not eaten anything. CR #1's family member stated CR#1 was still obstructed. CR#1 stated she did not remember much because nothing was being done and she asked them to make her food that was not spicy, without garlic and they did not do that. CR#1 stated she did not remember having a BM, and no one said anything about constipation. CR#1's family member stated on Thursday, (3/23/23) CR#1 was uncomfortable and Friday, (3/24/23) CR#1 was really (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 6 of 10 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 675663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Bend Healthcare Center 3010 Bamore Rd Rosenberg, TX 77471 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 - Few uncomfortable. The family member stated the NP was trying to prescribe Zofran for vomiting and he had not seen CR#1, but she told the facility no and said the NP needed to see CR#1. The family member stated the NP stated he heard no bowel sounds whatsoever. In an interview and record review on 4/5/23 at 2:30 p.m. with Local Hospital Manager over Nursing, she stated CR#1 was in the hospital with a diagnosis of severe sepsis on Total parenteral Nutrition and fat emulsion to help her nutrients. She stated CR#1 had restraints for a while because CR#1 was confused, and she also has a Peripherally inserted central catheter (PICC) line. The Manager stated the chief complaint from the emergency room was emesis and constipation. She stated there was fecal impaction and that meant CR#1 was not having bowel movements or only a little. She stated the facility should have stayed on top of water intake, diet that helps with bowel movement and they should keep up with stools. The Manager stated CR#1 still has the NG tube and it can still kill her. She stated surgery was still trying to see if they need to do surgery. In an interview on 4/5/23 at 2:45 p.m. with RN at local hospital, she stated the facility should have noticed CR#1 had not had a BM in multiple days. She stated the x-rays show small bowel obstruction and they have been giving her suppositories to get CR#1 to have a BM. CR#1 was receiving cleansing from both directions, and she was getting a lot and she was receiving nutrition through IV and getting fat through IV. In an interview on 4/6/23 at 7:15 a.m. with LVN D, she stated she worked the 10 p.m. to 6 a.m. shift and she assisted CR#1 Monday through Friday. LVN D stated on a Saturday, 3/18/23 the NP was in the facility and saw CR#1 and said she had no complaints other than she wanted something for constipation and she put her on lactulose prn. LVN D stated on that day LVN B was CR#1's nurse and CR#1's family member was at the facility. LVN D stated she saw LVN B talking to CR#1's family member and LVN D gave CR#1 meds that day because the other nurse was busy, but LVN D said she left before 2 p.m. LVN D stated when they do admission she palpates and taps with her hand to ensure there was no distension on her stomach. LVN D stated when she has residents with antibiotics and diuretic, she looks for nausea, hydration but CR#1 did fine with them. She stated CR#1 had small BM's daily. LVN D stated she would not think that if CR#1 ate 100% of her food, then she should not have had small BM's. LVN D stated she did not think anybody at the facility ate everything on their tray maybe 75% or 90%, but not 100%. On 3/25/23, Saturday morning she said the resident had not had her medicine yet and she gave her med's when she worked the day shift. LVN D stated the NP put CR#1 on lactulose prn 30 cc's, but she did not give it to CR#1 because she did not complain of constipation to her. LVN D stated as soon as she put the order in CR#1 could have gotten the lactulose, but she was not her nurse that day. LVN D stated CR#1 complained of constipation to the NP, and she did not give her the meds, but she was not her nurse that day. LVN D stated she did see dietary come out on that Saturday and show CR#1's family member the dietary slip and she did get her breakfast. LVN D stated that RN B said CR#1 was vomiting on 3/27/23 at 9:31 p.m., and she had a small amount of stool. LVN D stated that on 3/27/23 CR#1 had distension, and brown emesis. LVN D stated she did not know if CR#1 got the fleet enema. LVN D stated in the nurse note NP said lactulose was to be given now and daily PRN and there was an order for fleet enema and then she wrote oncoming nurse to follow up. LVN D stated the brown emesis to her was poop. LVN D stated she thinks somebody dropped the ball, but she was not at the facility. LVN D stated the documentation was not reflecting what should have happened, if CR#1 was given medication it was not documented. LVN D said CR#1 has a diagnosis of constipation, but record review of CR#1's treatment orders did not show fleet enema's and she did not see an order inputted at all. LVN D stated it was poop coming up, there was no way possible CR#1 was eating all her food. She stated there needed to be better monitoring for food and the amount they eat. LVN D stated the facility should have documented that she had the soup and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 7 of 10 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 675663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Bend Healthcare Center 3010 Bamore Rd Rosenberg, TX 77471 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 not the regular food. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 4/6/23 at 10:30 a.m. with CNA C, she stated when she worked with CR#1 on 3/27/23 on the 6 a.m. to 2 p.m. shift she stated that her stomach was hurting and that she had not gone to the restroom. CNA C stated LVN E told her she was going to get CR#1 something. CNA C stated CR#1 did not want to get up for lunch because she was in pain. CNA C stated CR#1 did not have a BM with her and it was hard to recall seeing if she had a slight smear of BM. CNA C stated she worked PRN, but CR#1 usually ate something. CNA C stated the day prior, 3/26/23 CR#1 was able to get up out of the chair and she was talkative, but the next day she did not feel good. CR#1 stated her stomach hurt, but she did not vomit that day. CNA C stated CR#1's family member came in and wanted something light for CR#1 to eat, she said her stomach could not take too much of certain foods. CR#1 stated she wanted something light for dinner. CNA C stated CR#1 felt bad on 3/27/23 and she was sick, so they laid her down because she was sick to her stomach at around after lunch. CNA C stated she does not ever remember CR#1 having a large BM. Residents Affected - Few In an interview and record review on 4/6/23 at 11:00 a.m. with the ADON, she stated she wrote the order for docusate sodium on 3/23/23 because CR#1's family said she was taking the Colace prior to her coming into the facility, but it was not on the hospital patient transfer medication list, and she called the NP and he said go ahead to give her the Colace (docusate sodium). The ADON stated before this, CR#1 was not on any medication for constipation. The ADON stated she did not assess CR#1 before or after administering the Colace. The ADON stated she does the circle of excellence for Care planning meetings, and she gave CR#1's family the medication list and goes over them. The ADON stated CR #1 was not on much medication and the family member did not say anything at that time. The ADON stated the family member stated the hospital increased the Lasix because her legs were so edematous, but she did not say CR#1 was having trouble going to the bathroom. The ADON stated they had monitoring for antibiotics and that was on the treatment sheet to take vitals, edema check Qshift, check the feet to make sure the feet, arms and legs were not swollen. She stated the antibiotics side effects would be rashes, decrease in appetite, hives, rash, nausea, suspected allergy, vomiting, anxious, chest pain, edema, diarrhea and the adverse reaction is the same. The ADON stated she checks the smart board for the treatments to ensure the nurses were documenting. The ADON stated the nurse that got the order for the enema was LVN B and she stated CR#1 had brown liquid emesis, and she gave CR#1 lactulose, but there were no results obtained and the NP gave the order for enema, but there were no results at that time. The ADON stated RN B was the night nurse and she said CR#1 had a small amount of brown stool. The ADON said she did check CR#1's MAR and she did not see lactulose or the enema as being given. The ADON stated they should have given the enema but when they put it on the schedule, they put the medication to start the next day. The ADON stated the Lactulose should have been given at 8 a.m. on 3/28/23, but it was not completed. The ADON stated RN B scheduled lactulose for the wrong day, and she does not know what to say about the lactulose. The ADON stated she saw the lactulose in the nurse note, but not in the MAR. The ADON stated LVN B stated she administered in CR#1 nurse notes and LVN B wrote that there were no results when the enema was administered. The ADON stated Lasix was not on the med list. She said she does not have any idea why it's not on the med list. She said the system should have populate the Lasix (furosemide) throughout the system. The ADON stated she added constipation in the face sheet because she had to have a reason for the Colace. She stated she could not explain why the CNA's say CR#1 ate 100% of her food and that CR#1 was having BM's, but she has started the in-service on today on documenting BM's. The ADON stated the CNA's should not document that it's a BM if it is just a smear or a little pebble, and liquid diarrhea needs to be reported to the charge nurse. The ADON stated if a patient eats, they need to document 100%, 75% and if the resident eats less than 50% and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 8 of 10 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 675663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Bend Healthcare Center 3010 Bamore Rd Rosenberg, TX 77471 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 - Few document if the resident eats the substitute. The ADON stated the staff had to start documenting. The ADON stated she thinks the documentation was not accurate and that was why they were going to start the in-servicing. In an interview on 4/6/23 at 11:43 a.m. with LVN C, she stated CR#1 was throwing up, she was weak, and constipated and those were the main things she called in to the hospital when CR #1 was sent out. LVN C stated CR #1 had a small BM the day before she was sent out, about the size of a tangerine. She stated CR#1 used to eat 75% to 100% of her meals on the 2 p.m. to 10 p.m. shift. She stated when they give antibiotics they watch to see if the resident has side effects such as nausea, vomiting, hives, fever when taking those meds. LVN C stated when they do head to toe assessments, they check the abdomen to see if it was tender or hard. LVN C stated she checked CR#1's abdomen when she was admitted to the facility, but she did not check it anymore because CR#1 did not have any complaints. In an interview on 4/6/23 at 11:57 a.m. with LVN B, she stated on 3/28/23 she went in to assess CR#1, trying to get CR#1 to turn and she had brown emesis on her gown in front of her and CR#1 did not really know that she vomited. LVN B stated she went to turn CR#1 and noticed her abdomen was distended, she was moaning when she tried to turn her, so she contacted the doctor to let him know what going on. LVN B stated the NP gave an order for lactulose, but the first administration did not work of lactulose. LVN B stated the NP said to give CR#1 a fleet enema, but CR#1 still did not get any results. LVN B stated that it was time for the shift to end so she (LVN B) told the night nurse, but could not recall who the night nurse was. LVN B stated Lactulose 30 ml was administered to CR#1 on 2 p.m. to 10 p.m. shift after dinner at 6:44 p.m. LVN B stated she contacted the NP and he stated to give CR#1 fleet enema. LVN B stated she did administer it, although it was not documented. LVN B stated she did not see how much dinner CR#1 ate, but she did not think she ate much. LVN B stated on 3/28/23 CR#1 did not have a full BM, just a smear. In an interview and observation on 4/6/23 at 12:05 p.m. with RN A and the ADON, RN A stated she worked with CR#1 one day (unknown date) and the aide said CR#1 vomited and she went to check her, and CR#1 said she was not constipated. RN A stated CR#1 threw up one time on 3/27/23 and she said she felt better, and RN A told CR#1 if she needed anything to call or if any vomiting and that's all she heard that day. RN A stated later at the end of the shift she heard CNA A say CR#1 vomited all day and RN A told CNA A wait a minute because she did not tell her CR#1 vomited all day. RN A stated she only saw CR#1 that morning. RN A stated she asked the aide if CR#1 had a BM and she said a little one. RN A stated she did not ask what size. RN A stated she did not document anything in CR#1's notes and she did not contact the NP or CR#1's family member. RN A stated she did not chart what the aide told her about CR#1. RN A stated she did not know if CR#1 vomiting was a change in condition. Observation at this time revealed RN A turned to the ADON and asked the ADON if CR#1's vomiting was a change in condition. The ADON told RN A that vomiting was a change in condition, and she was supposed to complete an SBAR. RN A stated she did not know she was supposed to complete an SBAR. RN A stated she checked CR#1's abdomen and it was not hard, and she did hear some bowel sounds. RN A stated CR#1 did not have active bowel sounds, but she could hear some bowel sounds. RN A stated she should have gone back and rechecked CR#1. RN A stated she did not see the throw up, the aide just told her. RN A stated if the aide would have told her she would have gone back and she would have called the Dr. RN A stated she went to see CR#1 again, but she was asleep. RN A stated she could not remember what meds CR #1 was on, but she would check vomiting, nausea, and diarrhea. RN A stated CR#1 did not appear dehydrated, and she did not get a report that CR#1 did not eat. RN A stated the aide stated CR#1 did not have a BM. RN A stated CR#1's abdomen was not distended in the morning at around 8 am or 9 a.m. RN A stated she did not remember what meds she administered to CR#1, but she did not give any PRN medication. RN A stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 9 of 10 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 675663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Bend Healthcare Center 3010 Bamore Rd Rosenberg, TX 77471 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 in hindsight she would have gone back in several times to check CR#1, and sometimes they get busy, but she should have gone back to see CR#1 again. RN A stated she did not go back to check with the aide again. RN A stated she heard the CNA A telling someone that CR#1 vomited all day and CNA A left at 2 p[TRUNCATED] Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 10 of 10