Inspection·July 25, 2023

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some *Diabetes Mellitus. Goals included: The resident will have no complications related to diabetes. Interventions included: Blood sugar checks as ordered. Medication as ordered. *Dialysis (Date initiated: 07/19/2023. Created by: LVN A). Goals included: The resident will have no s/sx of complications from dialysis. Interventions included: Assess shunt site for bruit (a rumbling sound that you can hear) and thrill (a rumbling sensation that you can feel). Dialysis treatment as ordered. Do not take blood pressure on the arm with shunt. Observe for bleeding at dialysis access site . Observation and interview with Resident #1 on 07/25/2023 at 1:05 p.m. revealed he was alert and oriented. Resident #1 was in bed and had multiple wound dressing on both legs. He stated he was admitted to the facility on Wednesday, 07/19/2023. He said things were rough in the beginning, but he had a talk with the boss (the ADON) and things were getting better. He said he previously always had dialysis on Mondays, Wednesdays, and Fridays, but since he had not been there for five months, the center gave his chair time away. He said he is now supposed to have dialysis on Tuesdays, Thursdays, and Saturdays. But this past Saturday, 07/22/2023, the facility did not take him. He said this was part of the problem he had in the beginning. He said the dialysis center was waiting for him and expecting him on Saturday, but the facility was just trying to get transportation for him. Resident #1 said whatever happened was a big screw up and he did not go to dialysis. He said the facility made arrangements for him to get dialysis on Monday, 07/24/2023. He said the last time he had dialysis before Monday was Wednesday, 07/19/2023. He said they were going to do it (dialysis) today (07/25/2023), but he had another appointment, so he will do it tomorrow, 07/26/2023. He said he now had to catch up. He said he was upset he missed so many treatments. He said they wanted to send him to the hospital over weekend, but someone, he did not know who, put a stop to that. Resident #1 said he got over it and he knew it would not happen again. Resident #1 said he did not feel sick like he thought he would after that many days without dialysis. Resident #1 said on Monday, 07/24/2023 the center took almost 3 kilos (of fluid), which was normal for him. He said judging by his weight, he could have used another treatment today, 07/25/2023. He said this was the first time he missed dialysis in six years. Record review of Resident #1's, Admission/readmission Collection Tool completed by LVN A and dated 07/19/2023 revealed, . 6. Care Needs/Special Instructions: (the name, address, and phone number for Resident #1's dialysis center was listed) Dialysis days Monday - Wednesday - Friday (these were his previous days, current days were Tuesday, Thursday, and Saturday) with chair time 11 a.m., transport in wheelchair . Admission/readmission Progress Note: Resident arrived at facility at 9:30 p.m. via stretcher . Resident has colostomy bag and does not make urine is a dialysis patient, goes on Tuesday - Thursday and Saturday .Alert and oriented x 4 . Record review of Resident #1's progress notes for July 2023 revealed the following: On 07/21/2023 at 6:51 a.m., RN B wrote, Day 2 Pot admission from acute care hospital with diagnosis of ESRD, Hemodialysis Tuesday, Thursday, Saturday . On Saturday, 07/22/2023 at 2:14 p.m., the ADON wrote, Resident dialysis for today rescheduled for Monday 07/24/2023 ONE TIME only visit for 10:45 a.m. EMS will pick up 10:00 a.m. Regular dialysis times Tuesday, Thursday, Saturday at 11:30 a.m. chair time with expected arrival of 11:15 a.m. EMS will pick up resident these days at 10:30 a.m. Charge nurse notified to place on 24-hour report and PCC (computer system) updated to reflect dialysis information. Resident aware of one-time appointment and regular pick-up times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 2 of 5 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 675671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Houston 7887 Cambridge St Houston, TX 77054 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 07/24/2023 at 3:25 p.m., the ADON wrote, Physician notified by this writer of resident rescheduled dialysis. Resident had no complications due to rescheduled dialysis appointment. On 07/24/2023 at 9:34 p.m., the ADON wrote, Received a call from resident stated he will not attend dialysis tomorrow, 07/25/2023 as he has and echo appointment with (the doctor's name and address was listed). EMS will pick up at 10:00 a.m. Resident notified of pick-up time. Resident will attend dialysis on Wednesday, 07/26/2023 at 11:00 a.m. chair time. EMS will pick up at 10:30 a.m. Resident notified of pick-up information. Charge nurse notified of appointment to place on 24-hour report. Record review of an in-service dated 07/24/2023 revealed the ADON educated nursing staff, including LVN A, RN B, and LVN C regarding dialysis orders. The document read in part, Associates are to ensure all dialysis orders/information are entered upon admission or when notification that a resident has dialysis. If a new resident arrives and has dialysis information, you re to contact dialysis center and obtain chair time and arrange transportation and make notation in PCC. If the resident does not have information or does not know, please notify nursing management immediately. Each dialysis resident is to be sent to dialysis with dialysis form and snack bag, no exceptions. Form must be completed upon return by dialysis facility and charge nurse. If form is incomplete by dialysis facility, please attempt to contact them to complete or give to ADON to assist in getting form completed. Charting must be done when resident leaves and returns from dialysis as well . In an interview with the ADON on 07/25/2023 at 10:20 a.m., she stated there were two residents on dialysis at the facility. She said Resident #1 was previously a resident at the facility and he sometimes refused dialysis. She said he canceled his dialysis treatment for that day, 07/25/2023 and Thursday, 07/20/2023 because he opted to go to other appointments. The ADON said Resident #1 maintained his own dialysis and he refused at times. She said Resident #1 did have dialysis on the previous day, 07/24/2023. The ADON said Resident #1 called his dialysis center on Saturday, 07/22/2023 and canceled that day to reschedule for Monday, 07/24/2023. She said Resident #1 was rescheduled for dialysis treatment for the next day, Tuesday, 07/26/2023 at 11:00 a.m. She stated Resident #1 did not experience any negative outcomes from not having dialysis multiple days. In an interview with LVN A and LVN C on 07/25/2023 at 12:47 p.m., LVN C stated Resident #1 had already returned from his appointment. LVN C said there were no new concerns with Resident #1, but he missed his dialysis appointment because it was not in the computer system when he was admitted . LVN C said the ADON would know why the dialysis appointment was not in the system, but she did not know why. LVN C said when dialysis residents were admitted from the hospital, the admitting nurse should follow-up with the dialysis center. LVN C said the resident may be able to give the date and time of their appointment, but the nurse should call and make sure the information was accurate. LVN C said another nurse (she did not say the nurse's name) said when Resident #1 was at the facility before, he went to dialysis on Mondays, Wednesdays, and Fridays. LVN C said the other nurse had to go into the computer and change the information. At that time, LVN A approached the nurse's station and stated said she was Resident #1's admitting nurse. LVN A said Resident #1 arrived late on 07/19/2023 and he told her where he went dialysis. LVN A said she wrote the information in the admit note and changed the old location to the new location. LVN A said Resident #1 missed his dialysis appointment on Thursday, 07/20/2023 because the other nurse (LVN C) did not have the dialysis information when he first admitted . LVN C said the facility did have the dialysis information when Resident #1 first admitted , but she (LVN C) did not get report from RN B before she left her shift (10:00 p.m. - 6:00 a.m. on 07/20/2023). LVN A stated she worked from 10:00 a.m. - 10:00 p.m. on 07/19/2023 and RN B worked the shift after her. LVN A said RN B did not give report that Resident #1 required dialysis to LVN C, who worked the 6:00 a.m. - 2:00 p.m. shift on 07/20/2023. LVN C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 3 of 5 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 675671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Houston 7887 Cambridge St Houston, TX 77054 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said since RN B did not pass on the information, she did not know she had a resident who needed dialysis until it was almost time for her to go home. LVN A said she wrote in the 24-hour report that they needed a chair time for Resident #1, but the paper she wrote the information on was not in the 24-hour book (she looked for the note she wrote but could not locate it). LVN A said they had just opened up that hall (the hall they placed Resident #1 one) and she did not know where the 24-hour book for that hall was. LVN C said LVN A was already gone when she (LVN C) got to work on 07/20/2023. LVN C said she knew LVN A would have been thorough with the information. In a follow up interview with LVN C on 07/25/2023 at 1:34 p.m., she stated when RN B left at the end of her shift on 07/20/2023, she (RN B) said, You got a resident on that side (the hall they had just opened/put residents on that was previously empty), but she never said he needed dialysis. LVN C said she was not sure what she (LVN C) looked at to know Resident #1 was supposed to go to dialysis. LVN C said the dialysis center called her on Thursday, 07/20/2023, when Resident #1 was supposed to be at dialysis, and she (LVN C) called the ADON and told her she did not know Resident #1 was supposed to have dialysis. She said the dialysis center called her because Resident #1 did not show up. LVN C said she was off on Saturday, 07/22/2023, she did not know why Resident #1 missed his dialysis appointment that day. LVN C said when the dialysis center called her on 07/20/2023 to ask if Resident #1 was on his way, she was giving report to LVN A who said she left the information about Resident #1's dialysis in a note in the 24-hour report book, but she did not have a chair time when she left the note. LVN C said she did not know there was a book back there because that side had been closed for several months. She said Resident #1 did not experience any negative outcomes from missing two dialysis treatments. In a telephone interview with a nurse at Resident #1's dialysis center on 07/25/2023 at 2:06 p.m., the nurse stated he called Resident #1 on Saturday, 07/22/2023 and he said he was having trouble getting a ride to the dialysis center. The nurse stated he called the facility's phone number, but someone put him on hold. The nurse said he called Resident #1 again and rescheduled him for Monday, 07/24/2023. The nurse stated Resident #1 was not at the dialysis center on Thursday, 07/20/2023 either but he did not know the reason. He said he was not aware of any negative result from Resident #1 missing two dialysis treatments. In an interview with LVN D on 07/25/2023 at 2:45 p.m., he stated he worked PRN at the facility mostly on the 2:00 p.m. - 10:00 p.m. shift. He stated he worked on Saturday, 07/22/2023 and when he went into Resident #1's room, he (Resident #1) said he was supposed to be going to dialysis. LVN D said he called the dialysis center, and he could not get in contact with anyone there. LVN D said he had to confirm the appointment to make sure. He said that was his first-time meeting Resident #1, so he had to do some homework regarding his dialysis. LVN D said when he called the transportation center, they said nothing had been set up for Saturday. He said the problem with Resident #1 was that he (Resident #1) told him (LVN D) he would take care of it. LVN D said he was trying to get Resident #1 there and set up transportation, but it was not going to work out for him anyway because he did not have a chair time. LVN D said he told Resident #1 they would take him to the hospital, but he did not want to do that. An attempt was made to contact Resident #1's doctor by phone on 07/25/2023 at 3:00 p.m. A message was left with a receptionist, but the call was not returned. Record review of facility policy, Hemodialysis Offsite Policy revised 08/18/2022 revealed, The facility assures that each resident receives care and services for the provision of offsite hemodialysis consistent with professional standards of practice. This includes; Arrangement for safe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 4 of 5 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 675671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Terrace Healthcare Center of Houston 7887 Cambridge St Houston, TX 77054 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 0698 transportation to and from the dialysis facility; . Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 5 of 5