Inspection·November 1, 2023

F 0580 at 08:57 AM. Level of Harm - Minimal harm or potential for actual harm - Lacosamide (a controlled substance used to treat seizures) 200 mg- take 1 tablet 2 times a day. - Clobazam 10 mg- ½ tablet by mouth 2 times a day. Residents Affected - Few - Levetiracetam( used to treat seizures) 1000 mg- take 1½ tablets by mouth 2 times a day. Record review of Resident #1's admission assessment dated [DATE] and signed by LVN A revealed, Resident #1 arrived at the facility at 03:05 PM, and the resident's medications were verified by NP A. LVN A wrote Resident #1 was reporting pain 10/10 at the time both feet stated she suffers from neuropathy (nerve pain). Record review of Resident #1's Pain Level Summary dated 10/23/23 at 6:56 PM signed by LVN A revealed, Resident #1 reported pain at 10 out 10. Record review of Resident #1's Order Summary dated 10/26/23 revealed, - Clobazam 5 mg Film, give 5 mg by mouth twice a day. The order was entered incorrectly as film instead of tablets as ordered in the hospital discharge, - Gabapentin 100 mg- - take 2 capsule 3 times a day. - Lacosamide 200 mg- take 1 tablet 2 times a day. Record review of Resident #1's Order Summary dated 10/31/23 at 12:38 PM revealed, - Clobazam 10 mg- give ½ tablet by mouth 2 times a day- ordered on 10/26/23 Record review of Resident #1's October MAR printed 11/01/23 at 09:37 AM revealed, Resident #1 did not receive the following medication. - Clobazam 5 mg Film- give 5 mg mouth due in the evening of 10/23/23, on 10/24/23 due at 08:00 AM and 4:00 PM, on 10/25/23 due at 8:00 AM. - Gabapentin 100 mg- - take 2 capsules by mouth due in the evening of 10/23/23. - Lacosamide 200 mg- take 1 tablet by mouth due in the evening of 10/23/23 and on 10/24/23 due at 08:00 AM and 04:00 PM. Record review of Review of Resident #1's October Progress Notes revealed, Resident #1's seizure medications were not available upon admission and documentation was as follows: - 10/24/23 AT 5:24 PM signed by LVN B- Clobazam 5 mg Oral Film and Lacosamide 200 mg Tablets were on order. There was no documentation of notifying the NP/MD, Administrator or DON that the medications were unavailable. - 10/24/23 at 09:07 AM signed by LVN B- Clobazam 5 mg Oral Film was on back order. There was no documentation of notifying the NP/MD, Administrator or DON that the medications were unavailable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 2 of 36 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 11/01/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few There was no documentation of notifying the NP/MD, Administrator or DON that medications were unavailable prior to the surveyor notifying the facility of the unavailable medications on 10/24/23 at approximately 4:00 PM. - On 10/31/23 at 01:45 PM signed by LVN D revealed, the NP placed an order for STAT labs due to Resident #1's altered mental status Record review of Resident #1's OT Treatment Notes dated 10/27/23 signed by the OT revealed, actively participates with skilled interventions. Record review of Resident #1's OT Treatment Notes dated 10/30/23 signed by the OT revealed, patient required extra time to process and sequence tasks at hand. Verna; cues given for task initiation during dressing tasks. Record review of Resident #1's ST Treatment Notes dated 10/27/23 signed by the ST revealed: Patient given a photo and instructed to recreate the model given several puzzle pieces. Completed the task with 70% accuracy given 0% cues increasing to 100% accuracy given min verbal/visual cues. Barriers impacting treatment-no Record review of Resident #1's ST Treatment Notes dated 10/30/23 signed by the ST revealed, Patient completed the task with 50% accuracy given 0% cues increasing to 70% accuracy given mod verbal/visual cues. Barriers impacting treatment-yes. Record review of Resident #1's ST Treatment Notes dated 10/31/23 signed by the ST revealed, Patient completed the task with 40% accuracy given 0% cues increasing to 70% accuracy given min-mod verbal/visual cues. Noted patient required more cuing to initiate each task during today's session. Barriers impacting treatment: yes limitations learning complex information. Record review of Resident #1's Psychiatric Physician Progress Notes dated 10/31/23 revealed, Resident #1's ordered medication Clobazam has a side effect of paranoia. He wrote the Resident #1 was drowsy and said she hears things and sees people which was kind off upsetting. Resident #1 was positive for visual and auditory hallucinations, with mild paranoia, apathetic(showing or feeling no interest, enthusiasm or concern) and anergic (continual feeling of tiredness, lack of energy or sleepiness which is often a symptom of mental health disorders). Resident #1's hallucinations are likely post ictal (due to a seizure) and from side effects of Clobazam. Record review of Resident #1 Provider Progress Note dated 10/31/23 written by NP B revealed, Resident #1 was seen for evaluation of acute changes related to somnolence incoherence, drowsiness and disorientation. NP B met with the Resident #1's family member and the surveyor in the resident's room at which point the family member said she was concerned about Resident #1's disorientation/pain and wanted to know what her current medications were. Patient noted sitting by bedside in no immediate distress but appeared weak and slower in responding to questions. Diagnosis, Assessment and Plan- Altered Mental status, unspecified, concern of disorientation/incoherence/drowsiness; will order labs. Lethargy- order labs, lower Gabapentin, discontinue Tylenol and monitor for worsening of symptoms. An observation and interview on 10/25/23 at 09:40 AM revealed, Resident #1 lying in bed, well dressed, well fed in no immediate distress. She said when she admitted 2 days ago her pain medications were not available as well as some other medications on her med list. Resident #1 said when she arrived at the facility she had pain at 10 out 10 and it was so bad she could not sleep but the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 3 of 36 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 11/01/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few did not administer her Gabapentin because her medication had not arrived yet. Resident #1 said she was currently experiencing pain and needle pain in both her feet but she could not provide a pain scale. There was no observed cognitive deficit, Resident #1 was energetic and very responsive. In an interview on 10/25/23 at 09:45 AM, the Surveyor notified LVN B, that Resident #1 was reporting pain in her feet. She said she had just administered Gabapentin to Resident #1 and the resident did not report pain. LVN B said she would assess Resident #1 for pain again. In an interview on 10/25/23 at 01:00 PM, the Administrator said the IP had the authority to answer questions regarding the facilities nursing practices because at the time she assisted the DON in performing nursing administration tasks. In an interview on 10/25/23 at 04:50 PM, the IP said she nor the DON were notified of any delays in the receiving or administration of Resident #1's seizure meds. She said she did not know the resident's Clobazam was not available, or there were delays receiving her Lacosamide. She said the NP/MD had not been notified. In an interview on 10/25/23 at 05:10 PM, the Surveyor notified the DON and Administrator that Resident #1's medication was unavailable and on back order. The DON and Administrator said they were never informed by nursing staff about any availability issues with Resident #1's seizure meds and they would immediately talk to the NP to get an alternative. She said the NP/MD had not been previously notified. In an interview on 10/26/23 at 09:25 AM, the pharmacist said, the facility first received an eScript for Lacosamide 200 mg for Resident #1 on 10/24/23 at 01:09 PM and NP B verbally called in a prescription for Clobazam 10 mg on 10/25/23 at 05:30 PM. He said NP B sent in a prescription for Clobazam 5 mg Film and not tablets on 10/24/23 at 07:00 PM but that medication has been unavailable due to manufacturer production issues for a prolonged period of time so it would not be available, In an interview on 10/26/23 at 10:22 AM, NP B said she was not Resident #1's admitting NP and that she was first notified of Clobazam being unavailable for Resident #1 in the evening of 10/25/23. She said she saw the patient on Tuesday 10/24/23 but did not receive any notifications of medication availability issues until Wednesday 10/25/23. NP B said when a resident admits after 6 PM nursing staff is expected to call in the medication with the on-call provider. She said she was not aware that Resident #1 discharge orders were for ½ of the 10 mg tablets and never for the film. NP B said she expects medications should be ordered and next doses administered pursuant to the hospital discharge orders. NP B said prior to the evening of 10/25/23 she was not notified that Resident #1 did not receive any seizure meds (Levetiracetam, Lacosamide, Clobazam) on the evening of her admission, Lacosamide and Clobazam on 10/24/23 and the Clobazam on the morning of 10/25/23. She said once she was notified of the issues with the Clobazam she immediately called in a prescription to the pharmacy for a 3 days' supply of Clobazam 10 mg tablets. NP B said she expected nursing staff to notify her of any medication availability issues immediately so she could place an order for an alternative and the pharmacy could do a stat delivery. NP B said failure to administer medications like Levetiracetam, Clobazam and Lacosamide placed residents at risk for seizures. She said she saw Resident Tuesday, 10/24/23, and the resident complained of pain on her big toe so she prescribed Tylenol as needed, but she was never informed that the resident complained of other pain or the facility failing to administer her Gabapentin on admission when the resident reported pain at 10 out of 10. NP B said she expected nursing staff to have administered Gabapentin to Resident #1 upon admission if she reported pain at 10 out 10, and that she should have been notified of the resident's pain. She said on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 4 of 36 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 11/01/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/25/23 she saw the resident to follow up on her seizure and pain medications and the resident complained of bilateral intermittent pain in her feet so she started Resident #1 on Tylenol #3 (a controlled substance used to treat pain) and increased her dose of Gabapentin. NP B said nursing staff should have notified her of Resident #1's continued pain. In an interview on 10/26/23 at 10;40 AM, LVN A said she was the admitting nurse for Resident #1 on 10/23/23. She said when a new resident is admitting the facility the nurse gets a verbal report from the discharging facility before the resident arrives and once the resident arrives they receive the discharge packet. LVN A said the residents medications are verified with the NP from the discharge packet and the medications are started based on the documented next dose. She said she could not remember when she entered Resident #1's medication to start but the resident reported pain at 10 out of 10 so she gave her Gabapentin and received/administered an order for Tylenol but she did not document it in the MAR or EMR. LVN A said Resident #1 said her feet were hurting really bad so she contacted NP A who gave her verbal orders for Tylenol but she never documented the order in the chart. When asked if Resident #1 continued to have pain after admission she said she honestly, didn't remember. LVN A said she did not go back to check on the resident until 9 or10 PM and she did not call the NP to follow up on Resident #1's pain. LVN A said nursing staff are expected to follow up with the provider for issues regarding pain or medications but it was too busy that night. LVN A said she couldn't say Resident #1's Levetiracetam or other seizure meds were on her mind when she talked to the NP and she would not know if the medication was in the EKit or not. She said she did not realize that she entered Resident #1's Clobazam as a film instead of tablets and she said failure to enter medications/administer medications as ordered could place residents at risk of continued/uncontrolled pain, seizures, medication error, adverse reactions and unavailability of medications. In an interview on 10/26/23 at 01:30 PM, NP A said she was the admitting nurse for Resident #1 on 10/23/23. She said LVN A called her and read the resident's hospital discharge medications to her and she gave an order to start all medications as listed in the discharge record. NP A said she did not make any changes to Resident #1's medication order included formulations to be administered or start times. She said she expected Resident #1's medications to be started according to the next dose due as listed on the hospital record. NP A said she did not give LVN A instructions to change from Clobazam tablets to Clobazam film and LVN A never reported that Resident #1 was experiencing pain at 10 out 10 upon admission. She said she expected LVN A to administer Gabapentin to the resident as ordered if she experienced pain, she said she did not order any additional pain medications because she was not aware the resident was reporting pain, and she expected to be notified if the resident was having pain so she could take appropriate action. NP A said she was not aware nor was she informed that Lacosamide and Clobazam were controlled substances required an eScript so she did not send a prescription to the pharmacy. NP A said she remembers this specifically because LVN A was concerned about Resident #1 receiving her Zolpidem (a controlled substance used for sleep) so she made sure to notify the MD to send the prescription. NP A said Resident #1 attending physician was changed immediately after admission so she was no longer her provider, but she said failure to administer medications as orders could place Resident #1 at risk for continued/irretractable pain and seizures. An observation and interview on 10/31/23 at 10:25 AM, Resident #1 appeared confused, she just stared down when asked questions by the surveyor. When the resident would response her answers were short phrases and were not always appropriate. Resident #1's family member said Resident #1 had been experiencing increased confusion since 10/25/23. She said on admission Resident #1's cognition upon admission was the same as it was at home, she had no kind of confusion, and her only limitations were physical which is why she was receiving therapy. The family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 5 of 36 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 11/01/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few member said she was concerned about Resident #1's medications because changes were made in the hospital, she said Resident #1's Levetiracetam was changed in the hospital and some additional seizure medications were started. The family member said she was the resident's POA and she was never notified of any difficulties acquiring Resident #1's seizure medication. The family member said she was really concerned about the confusion because it could stop her therapy progression. The family member said Resident #1 was mentally below her baseline at admission and her last ST session was not as successful as the previous weeks. She said she had informed an unknown nurse of Resident #1's increased confusion, wanted to see the doctor and she was awaiting a response. In an interview on 10/31/23 at 10:48 AM, NP B said she was not notified about a mental change of condition in Resident #1 and she saw the resident yesterday (10/30/23). An observation and interview on 10/31/23 at 11:05 AM revealed, NP B assessing Resident #1. When NP B asked the resident how she was doing she said my sister wants to talk to you. When NP B asked the resident questions, she was slow to answer, stared off and provided short answers. In an interview on 10/31/23 at 11:23 AM, NP B said Resident #1 appeared to be more sedated, delayed in her responses and stared at her sister when she was asked questions. She said the resident had experienced a change since she last saw her, and that previously Resident #1 provided robust answers and held conversations. NP B said Resident #1 had experienced a change of condition, so she would order labs and make some changes to her medication regimen. The NP said prior to seeing the resident today (10/31/23) she had not been notified or observed of Resident #1 experiencing a change of condition. In an interview on 10/31/23 at 01:32 PM, the ST said she had noticed a change of condition in Resident #1 compared to the previous week. She said the resident was more delayed when she worked with her yesterday. She said Resident #1 took longer to complete tasks and required more queuing. The ST said Resident #1 is not as verbose now and would only provide 1 word answers. When asked who she notified, the ST said she just documented it in her notes. In an interview on 10/31/23 at 12:00 PM, LVN D said she did not have enough conversation with Resident #1 to determine if she was confused but did appear tired today. She said upon admission the resident was not slow to respond, very chatty and interactive. In an interview on 10/31/23 at 01:45 PM, the OT said upon admission Resident #1 was talkative, carrying on conversations, alert, active and energetic. She said now Resident #1 is more flat and she has to initiate conversations with the resident. The OT said the resident spends most of their interactions with her eyes closed. She said the change of condition is more visible in her ADL tasks, specifically dressing. The OT said previously Resident #1 would initiate dressing if her clothes were placed in front of her but now she just stares at the clothes and requires queuing/prompting to initiate dressing. The OT said she had not notified her observed changes in Resident #1 she just documented it in her notes. In an interview on 10/31/23 at 01:56 PM, the DON said he was not aware of a change of condition in Resident #1 prior to the surveyor notifying the facility in the morning (10/31/23). He said therapy never notified him and his expectation was that therapy staff would notify nursing administration as well as the providers of any resident change of condition. In an interview on 10/31/23 at 02:23 PM, LVN B said Resident #1 looked loopy and drowsy this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 6 of 36 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 11/01/2023 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning. She said therapy staff normally notify nursing of any observed changes in residents but they had not informed her of any changes today. In an interview on 10/31/23 at 04:45 PM, the IP said she was not aware Resident #1 had hallucinations and delusions. She said the resident was previously very chatty with her and she had not noticed and was not notified about a mental change of condition prior to the surveyor bringing it up. In an interview on 10/31/23 at 04:51 PM, the Psychiatric MD said his first time seeing Resident #1 was today (10/31/23), due to a request made by the DON. He said Resident #1 was having visual and auditory hallucinations currently and experiencing some scary thoughts. The Psychiatric MD said Resident #1 said her son would jump off a building. He said these Hallucinations were most likely due to her order for Clobazam and most likely a side effect due to a seizure. He said seizure side effects could last from days to a couple of weeks. The Psychiatric MD said it was not advisable to discontinue Resident #1's Clobazam because the benefits of the treatment outweighed the risk. In an observation and interview on 11/01/23 at 11:50 AM, Resident #1 was observed to be eating a facility plated meal. She was slow to respond to the surveyor's questions and when asked how she was feeling she answered sister fills my pill box. Resident #1 appeared confused and suffering from increased cognitive impairment in comparison to the surveyors observation on 10/25/23. In an interview on 11/01/23 at 12:55 PM, the Rehab director said Resident #1 was working with OT, PT and ST. He said review of notes show that therapy staff had observed a decline in Resident #1 cognition (observed by ST), and decline in dressing ADL (observed by OT). The Rehab Director said normally, therapy staff would notify the nurse on the floor, him and nursing administration of any changes of condition like what Resident #1 experience. He said he was first notified of Resident #1's decline after I notified the facility on 10/31/23. The Rehab director said in Resident #1's decline there was a communication failure as well as some issues with clinical judgement. He said failure to communicate acute change of conditions could place residents at risk of worsening health conditions. In an interview on 11/01/23 at 01:40 PM, the DON said some side effects of seizures included prolonged lethargy, change in cognition and change in function. He said after her was notified of Resident #1's change of condition by the surveyor on 10/31/23 he immediately requested the Psychiatric MD see the Resident. He said prior to 10/31/23 there were no indications that Resident #1 needed to be followed by psychiatric services. The DON said the expectation is that any person who observes a change of condition notify nursing management, and the provider if possible. He said failure to give the appropriate notifications following changes of condition could place residents at risk of decline in health, late identification of acute problems and worsening health. Record review of the facility policy titled Changes in Resident's Conditions or Status revised 08/09/23 revealed, Notification of Changes- A facility must immediately inform th resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives(s) when there is: b- a significant change in the resident's physical, mental or psychosocial status (that is a deterioration in health, mental ) c- a need to alter treatment significantly (a need to discontinue an existing treatment due to adverse consequences, or to commence a new form of treatment). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 7 of 36 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 11/01/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 7 residents (CR #1) reviewed for quality of care. Residents Affected - Few - The facility failed to accurately enter and provide wound care to CR #1 surgical incision site and sacrum after admission for surgical aftercare on 08/03/23 and 08/04/23. This failure could place residents at risk of worsening of current wounds as well as infection. Findings Included Record review of CR #1's Face Sheet dated 10/25/23 at 11:42 AM revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: femur fracture and an encounter for orthopedic aftercare. The resident was transferred to the hospital on [DATE] and never returned to the facility. Record review of CR #1's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 01 out of 15. Record review of CR #1's Hospital Records dated 08/02/23 at 10:21 AM revealed, CR #1 admitted to the hospital on [DATE] and discharged on 08/02/23 CR #1 was admitted to the hospital after experiencing a fall resulting in a hip fracture that required surgery. There was no documentation of CR #1 suffering from any wounds to her sacrum, her skin was noted to have no significant lesions or rashes. Record review of CR #1's admission assessment dated [DATE] and signed by LVN C revealed, CR #1 admitted to the facility on [DATE]at 10:22 PM, with a surgical incision and an open area/wound. The wounds were described as left hip/thigh- incision in three places, covered with gauze/dry dressing; sacrumshearing and redness. Record review of CR#1's NP Progress Notes dated 08/03/23 signed by NP B revealed, Skin- left hip incision with dressing intact. There was no documentation of a sacral wound. Record review of CR#1's NP Progress Notes dated 08/04/23 signed by NP B revealed, Skin- left hip incision with dressing intact. Record review of CR #1's Wound Observation Tool dated 08/04/23 at 05:12 PM and signed by the DON revealed, CR #1 admitted with a surgical wound to her lower left leg on 08/02/23 and the wound measured 2.5 cm x 0.1 cm and had 3 staples. There were no signs of infection, CR #1 reported no pain and the current treatment plan was to apply TAO and cover with a dry dressing. Record review of CR #1 Order Summary Report revealed there were no wound care orders active prior to 08/05/23. - Orders for wound care to left lower extremity wound- clean with NS, apply TAO and cover with non-stick dressing daily was entered on 08/04/23 but was not started until 08/05/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 8 of 36 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 11/01/2023 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 0684 Record review of CR #1 August Progress Notes dated revealed, Level of Harm - Minimal harm or potential for actual harm - 08/05/23 at 04:40 PM signed by the IP-, LVN D performed wound care to CR #1's surgical wound. This was the first documentation of wound care. Residents Affected - Few - 08/05/23 at 9:23 PM signed by LVN E-, resident (family member) called 911 an insisted that resident go to (a hospital) at med center resident stated that she wanted to go for concerns about wound care on call md notified. - 08/11/23 at 06:53 PM, signed by LVN F- resident had an unwitnessed fall and was transferred to the hospital. Record review of CR #1's August MAR revealed, Orders for wound care to left lower extremity woundclean with NS, apply TAO and cover with non-stick dressing daily was entered on 08/04/23 at 04:38 PM and the first time the treatment was performed was on 08/08/23. Record review of CR #1's Surgical Consult note dated 08/07/23 at 07:16 PM and signed by the Wound Care MD revealed, . Preoperative indication- breakdown of tissue slough or dead tissues, poor healing; signs of infection: none. Procedure performed: surgical removal of subcutaneous tissue resulting in a post-operational wound area of 6X8X0.2 cm (48sq cm); wound progress: first visit. Operative note: CR #1 had a wound on her sacrum that was debrided (surgical removal of damage tissue). Record review of CR#1's NP Progress Notes dated 08/08/23 signed by NP B revealed, sacral wound present- unable to assess. There was no plan for the treatment of CR #1 sacral ulcer. Record review of CR#1's NP Progress Notes dated 08/11/23 signed by NP B revealed, Skin- left hip incision. Sacral Ulcer stage 3- 6X8X0.2 cm. Diagnosis/Assessment/Plan- sacral ulcer treatment with local wound care with Medihoney and Calcium Alginate In an interview on 10/25/23 at 11:00 AM, the DON said when CR #1 on the day admitted to the facility a skin assessment was performed and the nurse should have entered orders for the default wound care protocol until the wound care doctor saw the patient. He said after reviewing the patient's chart he did not see any reason why after CR #1's admission on [DATE] she did not receive wound care until 08/05/23. The DON said he assessed CR #1' He said he was not aware that CR #1 called 911 for the resident to go to the hospital due to concerns for wound care. In an interview on 10/25/23 at 11:32 AM, the DON said the floor nurses perform wound care but he is responsible for auditing to ensure wound care is being administered. He said the facility had default wound care orders to provide immediate care before the resident was seen by the wound care doctor. He said CR #1 should have had wound care orders for her surgical site upon admission. In an interview on 10/25/23 at 01:00 PM, the Administrator said the IP had the authority to answer questions regarding the facilities nursing practices because at the time she assisted the DON in performing nursing administration tasks. In an interview on 10/25/23 at 01:15 PM, the DON said he is responsible for wound observations upon admission because LVNs are not qualified to stage wounds. He said if a resident presented with redness and shearing as well as a surgical incision he should have looked at both sites. The DON said he knew he looked at CR #1's incision site. The DON said failure to provide wound care upon admission (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 9 of 36 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 11/01/2023 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 0684 placed residents at risk for worsening of wounds and infections. Level of Harm - Minimal harm or potential for actual harm In an interview on 10/25/23 at 02:15 PM, CR #1's family member said the the dressing to her mother's surgical incision site appeared old/dingy and hanging off like no one was changing it. She said she asked the floor nurse what care was being provided for her mother's wounds and the staff member said she didn't have to tell her anything. CR #1's family member said she called 911 later that evening due to her concerns of inadequate wound care, she said at the facility her mother's wound worsened, with her surgical site appearing red/inflamed but once she went to the hospital it got better. Residents Affected - Few In an interview on 10/25/23 at 03:48 PM, LVN C said she was the admitting nurse for CR #1 but does not remember much except CR #1 was a sweet, nice lady. She said when a resident admits nursing staff are expected to assess the residents and any identified wound should have orders entered for immediate care and the facility had specific default wound care orders depending on the state of the wound. LVN C said she did not remember if she saw any wounds on CR #1, she did not have the authority to stage wounds, and staging was performed by the RN. LVN C said failure to enter orders for immediate care of wound could place residents at risk of worsening of the wound or infection. In an interview on 10/25/23 at 04:19 PM, LVN D said she was not CR #1's admitting nurse. She said on an unknown date between 08:00 AM and 01:00 PM CR #1's family member asked what the facility was doing for her mother's wound and asked to see the resident's medical record. LVN D said she would not be able to provide the family member with the record and the family member would have to wait for the appropriate department to arrive to make her request. LVN D said she remembered CR #1 as having a surgical incision with staples that was covered by a dressing and she did not think CR #1 had orders for Zinc Barrier cream that would be the appropriate treatment for abrasions/shearing. LVN D said failure to enter wound care orders and failure to receive wound care could place residents at risk for adverse reactions, worsening of wounds and infection. In an interview on 10/26/23 at 11:08 PM, the Wound Care MD said every newly admitted resident should receive a full skin assessments to identify any wounds that might be present. He said any newly identified wounds should receive wound care orders based on the facility's default standing orders to be performed daily. In an interview on 11/01/23 at 01:40 PM, the DON said any residents with wounds observed upon admission should receive immediate orders for care per the facility protocol. He said failure to enter orders per the protocol could result in adverse outcomes/worsening of wounds and the admission LVN did not have the ability to determine the severity of CR #1's wounds and it was beyond her scope. The DON said failure to perform wound care could lead to worsening of wounds and failure to identify and document wounds accurately could result in missed diagnoses, and delay in care. Record review of the facility policy Basic Skin Management revised 11/28/22 revealed, orders are required for skin and wound care. There are wound care protocol order in the EMR. Record review of the facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management revised 03/31/23 revealed, provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury. 7- When skin breakdown occurs, it requires attention and a change in plan of care may be indicated to treat the resident. Record review of the facility undated Wound Care Order Protocol provided on 10/31/23 revealed, All admissions with wounds, including surgical, need wound care orders. Nurse completing admission is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 10 of 36 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 11/01/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm responsible for entering wound care orders in [EMR] and entering wound consult order. The documented protocol orders were as follows: - If the wound is draining and has exposed wound bed- cleanse wound with NS/Vashe, pat dry, lightly pack with Vashe moistened gauze and cover with dressing daily and PRN. Residents Affected - Few - If the wound is not draining and has an exposed wound bed- cleanse with Vashe/NS, pat dry, apply triad paste and cover with a dry dressing daily and PRN. - If resident has a surgical wound with sutures and staples- Betadine paint, let air dry and cover with dry dressing daily and PRN. - If resident has a deep tissue injury- Betadine paint and cover with foam dressing daily/PRN. - For all redness- apply barrier cream after each incontinent episode. FAILURE TO COMPLY WITH POLICY WILL RESULT IN DISCIPLINARY ACTION. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 11 of 36 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 11/01/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 7 residents (CR#1) reviewed for pressure sores. Residents Affected - Few -The facility failed to enter orders and provide wound care for CR #1's sacrum upon admission resulting in the resident going from shearing/redness to a stage 3 pressure ulcer. This failure could place residents at risk of worsening of current sores or the development of new pressure sores. Finding Included: Record review of CR #1's Face Sheet dated 10/25/23 at 11:42 AM revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: femur fracture and an encounter for orthopedic aftercare. The resident was transferred to the hospital on [DATE] and never returned to the facility. Record review of CR #1's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 01 out of 15. Record review of CR #1's Hospital Records dated 08/02/23 at 10:21 AM revealed, CR #1 admitted to the hospital on [DATE] and discharged on 08/02/23 CR was admitted to the hospital after experiencing a fall resulting in a hip fracture that required surgery. There was no documentation of CR #1 suffering from any wounds to her sacrum, her skin was noted to have no significant lesions or rashes. Record review of CR #1's admission assessment dated [DATE] and signed by LVN C revealed, CR #1 admitted to the facility on [DATE] at 10:22 PM, with an open area/wound. The wounds was described as sacrum- shearing and redness. Record review of CR#1's NP Progress Notes dated 08/03/23 signed by NP B revealed, there was no documentation of a sacral wound. Record review of CR#1's NP Progress Notes dated 08/04/23 signed by NP B revealed, there was no documentation of a sacral wound. Record review of CR #1's Wound Observation Tool dated 08/04/23 at 05:12 PM and signed by the DON revealed, CR #1 admitted with a surgical wound to her lower left leg on 08/02/23 and the wound measured 2.5 cm x 0.1 cm and had 3 staples. There were no signs of infection, CR #1 reported no pain and the current treatment plan was to apply TAO and cover with a dry dressing. There was no documentation of a sacral wound. Record review of CR #1's August Progress Notes dated revealed, - 08/05/23 at 9:23 PM signed by LVN E-, resident daughter called 911 an insisted that resident go to memorial [NAME] at med center resident stated that she wanted to go for concerns about wound care on call md notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 12 of 36 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 11/01/2023 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 0686 - 08/11/23 at 06:53 PM, signed by LVN F- resident had an unwitnessed fall and was transferred to the hospital. Level of Harm - Actual harm Residents Affected - Few Record review of CR #1's Order Summary Report revealed, there were no wound care orders active prior to 08/05/23. - Orders for Zinc Oxide paste- apply to sacral area topically every shift for skin protectant was entered on 08/05/23. - Cleanse sacral wound to Sacrum with Vashe solution, pat dry, apply Medihoney/calcium cover with dressing every day shift for sacral wound was entered on 08/07/23 and started on 08/08/23. Record review of CR #1's August MAR revealed, - the order for Zinc Oxide paste to the sacral order was entered on 08/05/23 at 05:44 PM and the first documented application was on the 08/05/23 night shift. Zinc Oxide was first applied to CR #1's sacrum on 08/06/23 at 03:37 AM. - the order to cleanse sacral wound to Sacrum with Vashe solution, pat dry, apply Medihoney/calcium cover with dressing every day shift for sacral wound was entered on 08/07/23 at 10:35 PM and it was first performed on 08/08/23. Record review of CR #1's Surgical Consult note dated 08/07/2 at 07:16 PM and signed by the Wound Care MD revealed, wound location- sacrum; cause: pressure injury/ulcer- wound stage: unstageable pressure injury. Preoperative indication- breakdown of tissue slough or dead tissues, poor healing; signs of infection: none. Procedure performed: surgical removal of subcutaneous tissue resulting in a post-operational wound area of 6X8X0.2 cm (48sq cm); wound progress: first visit. Operative note: CR #1 had a wound on her sacrum that was debrided (surgical removal of damage tissue). CR #1's sacral wound had signs of tissue breakdown which will need continuing surveillance and will likely require future debridement. Healing of these wound cannot be guaranteed as a result of the patient diagnoses/risk factors that affect the progress of this wound The patient has a chronic wound which may not heal and may worsen because of chronic comorbidities. Prognosis: prognosis for the patient's sacrum is poor. Record review of CR#1's NP Progress Notes dated 08/08/23 signed by NP B revealed, sacral wound present- unable to assess. There was no plan for the treatment of CR #1 sacral ulcer. Record review of CR #1's Skilled Wound Care Communication Log dated 08/08/23 revealed, a pressure injury/ulcer that was 6X8X0.2cm after debridement that had 50 % slough (a yellowish, moist, stringy substance that is a byproduct on inflammation during wound healing) and 50 % granulation (appearance of red, bumpy tissue in the wound bed as a wound heals) and no signs of infection. The recommended treatment was Calcium Alginate and Honey Daily. The wound was noted to be present on admission and unstageable. Record review of CR #1's Wound Observation Tool dated 08/10/23 at 03:03 PM and signed by the DON revealed, CR #1 had a stage 3 pressure ulcer with granulation and slough with moderate serous drainage that measured 6X8X0.2 cm, had possible deep tissue injury and no signs of infection. Record review of CR#1's NP Progress Notes dated 08/11/23 signed by NP B revealed, Skin- left hip (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 13 of 36 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 11/01/2023 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 0686 incision. Sacral Ulcer stage 3- 6X8X0.2 cm. Diagnosis/Assessment/Plan- sacral ulcer treatment with local wound care with Medihoney and Calcium Alginate Level of Harm - Actual harm Residents Affected - Few In an interview on 10/25/23 at 11:00 AM, the DON said when CR #1 on the day admitted to the facility a skin assessment was performed and the nurse should have entered orders for the default wound care protocol until the wound care doctor saw the patient. He said after reviewing the patient's chart he did not see any reason after CR #1's admission on [DATE] she did not receive wound care until 08/05/23. He said he was not aware that CR #1 called 911 for the resident to go to the hospital due to concerns for wound care. In an interview on 10/25/23 at 11:32 AM, the DON said the floor nurses perform wound care but he was responsible for auditing to ensure wound care is being administered. He said the facility had default wound care orders to provide immediate care before the resident was seen by the wound care doctor. He said CR #1 should have had wound care orders for her wound to her sacrum upon admission. In an interview on 10/25/23 at 02:15 PM, CR #1's family member said the resident did not admit to the facility with a wound to her sacrum and she saw no indication of a bed sore in the hospital. She said on 08/05/23 she came to see her mother in the morning and observed an open wound while turning her and with no dressing. She said she asked the floor nurse what care was being provided for her mother's wounds and the staff member said she didn't have to tell her anything. CR #1's family member said she called 911 later that evening due to her concerns of inadequate wound care. In an interview on 10/25/23 at 03:48 PM, LVN C said she was the admitting nurse for CR #1 but does not remember much except CR #1 was a sweet, nice lady. She said when a resident admits nursing staff are expected to assess the residents and any identified wound should have orders entered for immediate care and the facility had specific default wound care orders depending on the state of the wound. LVN C said she did not remember if she saw any wounds on CR #1, she did not have the authority to stage wounds, and staging was performed by the RN. LVN C said failure to enter orders for immediate care of wound could place residents at risk of worsening of the wound or infection. In an interview on 10/25/23 at 04:19 PM, LVN D said she was not CR #1's admitting nurse. She said on an unknown date between 08:00 AM and 01:00 PM CR #1's family member asked what the facility was doing for her mother's wound and asked to see the resident's medical record. LVN D said she would not be able to provide the family member with the record and the family member would have to wait for the appropriate department to arrive to make her request. LVN D said when she went to provide incontinence care to CR #1 she observed a wound on her sacrum that looked like abrasions and shearing but she did not remember if the resident had wound care orders. She said she remembers CR #1 as having a surgical incision with staples that was covered by a dressing and she did not think CR #1 had orders for Zinc Barrier cream that would be the appropriate treatment for abrasions/shearing. LVN D said failure to enter wound care orders and failure to receive wound care could place residents at risk for adverse reactions, worsening of wounds and infection. In an interview on 10/26/23 at 11:08 PM, the Wound Care MD said every newly admitted resident should receive a full skin assessments to identify any wounds that might be present. He said any newly identified wounds should receive wound care orders based on the facility's default standing orders to be performed daily. The Wound care MD said he was never notified of CR #1 not receiving wound care upon admission and he said based on his assessment, the application of Zinc Oxide was not appropriate because it only treats minimal breakdown that is moisture associated. The Wound Care MD said based on his assessment on 08/07/23, treatment with Honey + Calcium Alginate was appropriate for CR #1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 14 of 36 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 11/01/2023 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 0686 Level of Harm - Actual harm Residents Affected - Few wound. He said CR #1's wound measured at 6x8 cm after debridement with visible slough and it was unstageable. The Wound care doctor said he was unable to determine the stage of the wound even though he had a measured dent because the depth of a wound on different body types (skinny/fat/muscular) could determine the stage. The Wound Care MD said he was notified that the sacral wound was present on admission and it was not normal for a wound to go from shearing/redness to a stage 3 pressure ulcer during the short time CR #1 was admitted . In an interview on 10/31/23 at 03:49 PM, the IP said if a resident had redness/shearing at admission they should have received orders for barrier cream to start immediately upon admission. In an interview on 11/01/23 at 01:40 PM, the DON said any residents with wounds observed upon admission should receive immediate orders for care per the facility protocol. He said failure to enter orders per the protocol could result in adverse outcomes/worsening of wounds and the admission LVN did not have the ability to determine the severity of CR #1's wounds and it was beyond her scope. The DON said failure to perform wound care could lead to worsening of wounds and failure to identify and document wounds accurately could result in missed diagnoses, and delay in care. Record review of the facility policy Basic Skin Management revised 11/28/22 revealed, orders are required for skin and wound care. There are wound care protocol order in the EMR. Record review of the facility policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management revised 03/31/23 revealed, provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury. 7- When skin breakdown occurs, it requires attention and a change in plan of care may be indicated to treat the resident. Record review of the facility undated Wound Care Order Protocol provided on 10/31/23 revealed, All admissions with wounds, including surgical, need wound care orders. Nurse completing admission is responsible for entering wound care orders in [EMR] and entering wound consult order. The documented protocol orders were as follows: - If the wound is draining and has exposed wound bed- cleanse wound with NS/Vashe, pat dry, lightly pack with Vashe moistened gauze and cover with dressing daily and PRN. - If the wound is not draining and has an exposed wound bed- cleanse with Vashe/NS, pat dry, apply triad paste and cover with a dry dressing daily and PRN. - If resident has a surgical wound with sutures and staples- Betadine paint, let air dry and cover with dry dressing daily and PRN. - If resident has a deep tissue injury- Betadine paint and cover with foam dressing daily/PRN. - For all redness- apply barrier cream after each incontinent episode. FAILURE TO COMPLY WITH POLICY WILL RESULT IN DISCIPLINARY ACTION. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 15 of 36 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 11/01/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care and the facility failed to provide care which included but not limited to assessing, evaluating, planning and implementing resident care plans and responded to resident needs for 1 of 1 residents (Residents #1) and 1 of 3 nurses (LVN A) reviewed for nurse competency. 1. The facility failed to ensure LVN A was trained to admit residents, reconcile medications, administer medications, and assess pain prior to providing nursing services. This failure could place residents at risk of receiving inadequate care and harm. Findings included: Resident #1 Record review of Resident #1's Face Sheet dated 11/01/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: unspecified convulsion, type 2 diabetes, neuropathy (nerve pain), heart failure and high cholesterol. Record review of Resident #1's admission MDS dated [DATE] and printed on 11/01/22 at 09:22 AM revealed, intact cognition as indicated by a BIMS score of 13 out of 15. Record review of Resident #1's Baseline Care Plan dated 10/23/23 revealed, Focus: pain, goal- resident will express pain relief, interventions- pain meds as ordered and evaluate the effectiveness of pain interventions. Record review of Resident #1's Hospital Discharge Instructions dated 10/23/23 at 12:54 PM revealed, Resident #1 admitted to the hospital due to seizures and was observed having a seizure on 10/13/23 during a neurological consultation. Resident #1 discharged with the following medications with instructions for the next administered dose: - Clobazam (a benzodiazepine controlled substance used to treat seizures) 10mg, ½ tablet by mouth twice a day. Last dose given on 10/23/23 at 09:04 PM. - Gabapentin (used for nerve pain) 100 mg- take 2 capsule 3 times a day. Last dose given 10/23/23 at 08:57 AM. - Lacosamide (a controlled substance used to treat seizures) 200 mg- take 1 tablet 2 times a day. - Atorvastatin (used to treat high cholesterol) 80 mg- take 1 tablet by mouth nightly. Last dose given 10/22/23 at 08:53 PM. - Levetiracetam( used to treat seizures) 1000 mg- take 1½ tablets by mouth 2 times a day. - Apixaban (a blood thinner) 5 mg- 1 tablet by mouth 2 times a day. Last dose 10/23/23 at 08:57 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 16 of 36 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 11/01/2023 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 0726 - Metformin (used to control blood sugar) 500 mg- 1 tablet by mouth 2 times a day with meals. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's admission assessment dated [DATE] and signed by LVN A revealed, Resident #1 arrived at the facility at 03:05 PM, and the resident's medications were verified by NP A. NP A wrote Resident #1 was reporting pain 10/10 at the time both feet stated she suffers from neuropathy. Residents Affected - Some Record review of Resident #1's Pain Level Summary dated 10/23/23 at 6:56 PM signed by LVN A revealed, Resident #1 reported pain at 10 out 10. Record review of Resident #1's Order Summary dated 10/26/23 revealed, the following medications were entered on admission [DATE]) but were started on 10/24/23 the day after Resident #1 admitted to the facility: - Apixaban 5 mg- 1 tablet by mouth 2 times a day - Atorvastatin 80 mg- take 1 tablet by mouth nightly. - Clobazam 5 mg Film, give 5 mg by mouth twice a day. The order was entered incorrectly as film instead of tablets as ordered in the hospital discharge, - Gabapentin 100 mg- - take 2 capsule 3 times a day. - Lacosamide 200 mg- take 1 tablet 2 times a day. - Levetiracetam 1000 mg- take 1½ tablets by mouth 2 times a day. - Metformin 500 mg- 1 tablet by mouth 2 times a day with meals. Record review of Resident #1's October MAR printed 11/01/23 at 09:37 AM revealed, Resident #1 did not receive the following medication. - Apixaban 5 mg- 1 tablet by mouth due in the evening of 10/23/23. - Atorvastatin 80 mg- take 1 tablet by mouth due in the evening of 10/23/23. - Clobazam 5 mg Film- give 5 mg mouth due in the evening of 10/23/23, on 10/24/23 due at 08:00 AM and 4:00 PM, on 10/25/23 due at 8:00 AM. - Gabapentin 100 mg- - take 2 capsules by mouth due in the evening of 10/23/23. - Lacosamide 200 mg- take 1 tablet by mouth due in the evening of 10/23/23 and on 10/24/23 due at 08:00 AM and 04:00 PM. - Levetiracetam 1000 mg- take 1½ tablets by mouth due in the evening of 10/23/23. - Metformin 500 mg- 1 tablet by mouth due in the evening of 10/23/23. - Donepezil 10 mg 1 tablet by mouth due at 9 PM on 10/31/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 17 of 36 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 11/01/2023 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 0726 Record review of the facility undated EKit Contents revealed the facility had the following medications: Level of Harm - Minimal harm or potential for actual harm - 4 tablets of Donepezil 5 mg. - 4 capsules of Gabapentin 100 mg Residents Affected - Some - 4 tablets of Levetiracetam - 4 tablets of Metformin An observation and interview on 10/25/23 at 09:40 AM revealed, Resident #1 lying in bed, well dressed, well fed in no immediate distress. She said when she admitted 2 days ago her pain medications were not available as well as some other medications on her med list. Resident #1 said when she arrived at the facility she had pain at 10 out 10 and it was so bad she could not sleep but the facility did not administer her Gabapentin because her medication had not arrived yet. Resident #1 said she was currently experiencing pain and needle pain in both her feet but she could not provide a pain scale. In an interview on 10/26/23 at 09:25 AM, the pharmacist said, NP B sent in a prescription for Clobazam 5 mg Film and not tablets on 10/24/23 at 07:00 PM but that medication has been unavailable due to manufacturer production issues for a prolonged period of time so it would not be available, In an interview on 10/26/23 at 10;40 AM, LVN A said she was the admitting nurse for Resident #1 on 10/23/23. She said when a new resident is admitting the facility the nurse gets a verbal report from the discharging facility before the resident arrives and once the resident arrive they receive the discharge packet. LVN A said the residents medications are verified with the NP from the discharge packet and the medications are started based on the documented next dose. She said she could not remember when she entered Resident #1's medication to start but the resident reported pain at 10 out of 10 so she gave her Gabapentin and received/administered an order for Tylenol but she did not document it in the MAR or EMR. LVN A said Resident #1 said her feet were hurting really bad so she contacted NP A who gave her verbal orders for Tylenol but she never documented the order in the chart. When asked if Resident #1 continued to have pain after admission she said she honestly, didn't remember. NP A said she did not go back to check on the resident until 9/10 PM and she did not call the NP to follow up on Resident #1's pain. LVN A said nursing staff are expected to follow up with the provider for issues regarding pain or medications but it was too busy that night. LVN A said she couldn't say Resident #1's Levetiracetam or other seizure meds were on her mind when she talked to the NP and she would not know if the medication was in the EKit or not. She said she did not realize that she entered Resident #1's Clobazam as a film instead of tablets and she said failure to enter medications/administer medications as ordered could place residents at risk of continued/uncontrolled pain, seizures, medication error, adverse reactions and unavailability of medications. In an interview on 10/26/23 at 01:30 PM, NP A said she was the admitting nurse for Resident #1 on 10/23/23. She said LVN A called her and read the resident's hospital discharge medications to her and she gave an order to start all medications as listed in the discharge record. NP A said she did not make any changes to Resident #1's medication order included formulations to be administered or start times. She said she expected Resident #1's medications to be started according to the next dose due as listed on the hospital record. NP A said she did not give LVN B instructions to change from Clobazam tablets to Clobazam film and LVN B never reported that Resident #1 was experiencing pain at 10 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 18 of 36 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 11/01/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some out 10 upon admission. She said she expected LVN B to administer Gabapentin to the resident as ordered if she experienced pain, she said she did not order any additional pain medications because she was not aware the resident was reporting pain, and she expected to be notified if the resident was having pain so she could take appropriate action. NP A said she was not aware nor was she informed that Lacosamide and Clobazam were controlled substances required an eScript so she did not send a prescription to the pharmacy. NP A said she remembers this specifically because LVN B was concerned about Resident #1 receiving her Zolpidem (a controlled substance used for sleep) so she made sure to notify the MD to send the prescription. NP A said Resident #1 attending physician was changed immediately after admission so she was no longer her provider, but she said failure to administer medications as orders could place Resident #1 at risk for continued/irretractable pain and seizures. In an interview on 10/31/23 at 02:38 PM, the Medical Records Director said the facility did not complete nor have records of annual competency assessments for nursing staff. In an interview on 10/31/23 at 02:40 PM, the DON said the facility did not assess new hires that certain competencies were expected with their professional license. He said during orientation, new nurses are asked about areas of concern and additional training is provided on identified areas. In an interview on 10/31/23 at 03:05 PM, the IP said no one actually assesses nursing competency. Competency is signed off based on the online training. In an interview on 11/01/23 at 12:10 PM, LVN A said Resident #1 had just received a brand new order for Donepezil on 10/31/23 so she did not received it on the night of 10/31/23 because it was not available. LVN A said she did not know that Donepezil was available in the EKit. She said there was a list of medications that could be dispensed from the EKit but she does not believe she checked. LVN A said she started working with the facility in January of 2023 and she was never really trained on using the EKit, or admission medication reconciliation and she just learned on her own. She said failure to administer medication as ordered could place residents at risk for untreated health conditions. In an interview on 11/01/23 at 01:40 PM, training records for LVN A showed she was not trained on medication reconciliation/medication administration/documentation. He said he was responsible for ensuring training is completed by staff prior to working on the floor. When asked if staff with inadequate training should be allowed on the floor, the DON said each nurses licensure represented her nursing competency. In an interview on 11/01/23 at 02:35 PM, the Administrator said she was unaware that LVN A had not attempted her online training modules. She said on hire nursing staff go through a healthcare academy that has assigned courses they must complete. When asked if nursing staff should be on the floor if their training was not attempted/completed, the Administrator would not answer. She said training involved on the job training, training at orientation and continuous training during employment. In an interview on 11/01/23 at 02:55 PM, the DON said there was no competency check off completed on nurses on hire or annually but the facility would be providing assessments going forward. Record review of the facility Employee Roster dated 10/25/23 at 10:15 AM revealed, LVN A was hired on 01/30/23. Record review of LVN A's undated training record revealed, LVN A had not attempted majority of her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 19 of 36 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 11/01/2023 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 0726 training including: Level of Harm - Minimal harm or potential for actual harm - Pain Assessment and Management which was assigned on 01/31/23. - Introduction to Nursing documentation which was assigned on 01/31/23. Residents Affected - Some - Drug Diversion Prevention Program which was assigned on 04/20/23. - Nursing Staff Policies Attestation which was assigned on 01/31/23. - Introduction to Skin Care and Wound Care which was assigned on 01/31/23. Record review of the facility provided pharmacy Quick Reference document with no revision date revealed, If you place a new order after the daily cut-off times, and the medication is not in your EDK, fax the order and CALL the pharmacy to the inform them of the new order and when the resident will need the medication. New admissions, critical need medications are always available even after hours, CALL the pharmacy. Ordering [NAME]: Monday-Friday the cut off time for new medication orders and new admissions medications was 6:00 PM. All SNF facilities have the potential for 2 deliveries per day- leaving the pharmacy at 01:00 PM and 08:00 PM release times. Any new order must be received by the pharmacy 2 hours prior to the delivery release time and any critical medication-please call the pharmacy. Record review of the facility policy titled Medication Shortages/Unavailable Medication revised 01/01/22 revealed,2- If a medication is unavailable during normal pharmacy hours. 2.2- If the next available delivery causes delay or missed dose in the resident's medication schedule, facility nurse should obtain the medication from the emergency medication supply to administer the dose. 2.3- If the medication is not available in the emergency medication supply, facility staff should notify pharmacy and arrange for an emergency delivery, if necessary. 5- If the medication is unavailable from Pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate Physician/Prescriber orders, as necessary. When the pharmacy notifies the facility that a medication is unavailable due to a recall or manufacturer issue, facility staff should notify the physician/prescriber for a new order. 9-when a missed dose is unavoidable, facility nurse should document the missed dose and the explanation such documentation should include: a description of the circumstance of the medication shortage, a description of pharmacy's response upon notification and actions taken. Record review of the facility policy Medication Administration Times revised 01/01/22 revealed, 2- Facility should commence medication administration within 60 minutes before the designated times of administration and should be completed by 60 minutes after the designated times of administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 20 of 36 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 11/01/2023 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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 2 of 6 residents (CR #1 and Resident #1) reviewed for pharmacy services in that: - The facility failed to administer pain medications to Resident #1 as ordered upon admission after the resident reported pain at 10 out of 10. - The facility failed to acquire and administer medications to Resident #1 as ordered upon admission, with some seizure meds not administered until 2 days after admission. - The facility failed to accurately administer Resident #1's seizure medication Clobazam as ordered by administering Clobazam 10 mg tablets instead of 5mg films as documented in the EMR - The facility failed to retrieve Resident #1 initial dose of medications from the facility emergency kit. - The facility failed to administer medications timely to Resident #1. - The facility failed to administer tramadol to CR #1 as ordered upon admission after the resident reported pain at 5 out if 10. These failures could place residents at risk of not receiving medications as ordered by their physician, inadequate disease management, uncontrolled pain, seizures and serious harm. Findings included: Resident #1 Record review of Resident #1's Face Sheet dated 11/01/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: unspecified convulsion, type 2 diabetes, neuropathy (nerve pain), heart failure and high cholesterol. Record review of Resident #1's admission MDS dated [DATE] and printed on 11/01/22 at 09:22 AM revealed, intact cognition as indicated by a BIMS score of 13 out of 15. Record review of Resident #1's Baseline Care Plan dated 10/23/23 revealed, Focus: pain, goal- resident will express pain relief, interventions- pain meds as ordered and evaluate the effectiveness of pain interventions. Record review of Resident #1's Hospital Discharge Instructions dated 10/23/23 at 12:54 PM revealed, Resident #1 admitted to the hospital due to seizures and was observed having a seizure on 10/13/23 during a neurological consultation. Resident #1 discharged with the following medications with instructions for the next administered dose: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 21 of 36 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 11/01/2023 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 0755 - Clobazam (a benzodiazepine controlled substance used to treat seizures) 10mg tablets, ½ tablet by mouth twice a day. Last dose given on 10/23/23 at 09:04 PM. Level of Harm - Actual harm Residents Affected - Some - Gabapentin (used for nerve pain) 100 mg- take 2 capsule 3 times a day. Last dose given 10/23/23 at 08:57 AM. - Lacosamide (a controlled substance used to treat seizures) 200 mg- take 1 tablet 2 times a day. - Atorvastatin (used to treat high cholesterol) 80 mg- take 1 tablet by mouth nightly. Last dose given 10/22/23 at 08:53 PM. - Levetiracetam( used to treat seizures) 1000 mg- take 1½ tablets by mouth 2 times a day. - Apixaban (a blood thinner) 5 mg- 1 tablet by mouth 2 times a day. Last dose 10/23/23 at 08:57 AM. - Metformin (used to control blood sugar) 500 mg- 1 tablet by mouth 2 times a day with meals. Record review of Resident #1's admission assessment dated [DATE] and signed by LVN A revealed, Resident #1 arrived at the facility at 03:05 PM, and the resident's medications were verified by NP A. LVN A wrote Resident #1 was reporting pain 10/10 at the time both feet stated she suffers from neuropathy. Record review of Resident #1's Pain Level Summary dated 10/23/23 at 6:56 PM signed by LVN A revealed, Resident #1 reported pain at 10 out 10. Record review of Resident #1's Progress Notes dated 10/25/23 at 09:51 PM and signed by LVN A revealed. clobazam 5mg tablets just arrived from pharmacy NP verbal order per DON to give when it arrived. Record review of Resident #1's Pharmacy Records dated 10/30/23 revealed, - An electronic prescription for Lacosamide 200 mg was not sent until 10/24/23 at 02:09 PM. - An electronic prescription for Clobazam 5 mg film (a backordered product) instead of Clobazam 10 mg tablets as ordered on the hospital discharge records was first sent to the pharmacy on 10/24/23 at 07:01 PM. Record review of Resident #1's Order Summary dated 10/26/23 revealed, the following medications were entered on admission [DATE]) but were started on 10/24/23 the day after Resident #1 admitted to the facility: - Apixaban 5 mg- 1 tablet by mouth 2 times a day - Atorvastatin 80 mg- take 1 tablet by mouth nightly. - Clobazam 5 mg Film, give 5 mg by mouth twice a day. The order was entered incorrectly as film instead of tablets as ordered in the hospital discharge, - Gabapentin 100 mg- - take 2 capsule 3 times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 22 of 36 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 11/01/2023 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 0755 - Lacosamide 200 mg- take 1 tablet 2 times a day. Level of Harm - Actual harm - Levetiracetam 1000 mg- take 1½ tablets by mouth 2 times a day. Residents Affected - Some - Metformin 500 mg- 1 tablet by mouth 2 times a day with meals. Record review of Resident #1's Order Summary dated 10/31/23 at 12:38 PM revealed, - Clobazam 10 mg- give ½ tablet by mouth 2 times a day- ordered on 10/26/23 Record review of Resident #1's Physician Order dated 10/31/23 revealed, Donepezil 10 mg- 1 tablet by mouth at bedtime for dementia. Record review of Resident #1's October MAR printed 11/01/23 at 09:37 AM revealed, Resident #1 did not receive the following medication. - Apixaban 5 mg- 1 tablet by mouth due in the evening of 10/23/23. - Atorvastatin 80 mg- take 1 tablet by mouth due in the evening of 10/23/23. - Clobazam 5 mg Film- give 5 mg mouth due in the evening of 10/23/23, on 10/24/23 due at 08:00 AM and 4:00 PM, on 10/25/23 due at 8:00 AM. - Gabapentin 100 mg- - take 2 capsules by mouth due in the evening of 10/23/23. - Lacosamide 200 mg- take 1 tablet by mouth due in the evening of 10/23/23 and on 10/24/23 due at 08:00 AM and 04:00 PM. - Levetiracetam 1000 mg- take 1½ tablets by mouth due in the evening of 10/23/23. - Metformin 500 mg- 1 tablet by mouth due in the evening of 10/23/23. - Donepezil 10 mg 1 tablet by mouth due at 9 PM on 10/31/23. Resident #1 was administered Clobazam 5 mg Film on the following days when the medication was not available: 10/25/23 scheduled for the 4:00 PM evening dose. 10/26/23 scheduled for the 8:00 AM morning dose. Record review of Resident #1's Medication Audit Report dated 11/01/23 at 01:27 PM revealed, the facility failed to administer medications timely (+/- 1 hr. of the scheduled administration time) to Resident #1 on 69 different occasions between 10/24/23 and 11/01/23 with no documented reason: The morning of 10/24/23 1Gabapentin 100 mg- 2 capsules scheduled for 08:00 AM and administered at 10:34 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 23 of 36 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 11/01/2023 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 0755 2- Level of Harm - Actual harm Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 08:00 AM and administered at 10:34 AM. Residents Affected - Some 3Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 10:34 AM. 4Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 10:34 AM. The evening of 10/24/23 5Gabapentin 100 mg- 2 capsules. Scheduled for 04:00 PM and administered at 05:25 PM. 6Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 04:00 PM and administered at 05:25 PM. 7Metformin 500 mg- 1 tablet with meals. Scheduled for 04:00 PM and administered at 05:25 PM. 8Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 05:25 PM. The morning of 10/25/23 9Gabapentin 100 mg- 2 capsules scheduled for 08:00 AM and administered at 09:20 AM. 10Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 08:00 AM and administered at 09:21 AM. 11Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 09:21 AM. 12Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 09:20 AM. 13(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 24 of 36 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 11/01/2023 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 0755 Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 09:21 AM. Level of Harm - Actual harm The afternoon of 10/25/23 Residents Affected - Some 14Gabapentin 100 mg- 2 capsules scheduled for 12:00 PM and administered at 02:28 PM. The evening of 10/25/23 15Gabapentin 100 mg- 2 capsules. Scheduled for 04:00 PM and administered at 06:39 PM. 16Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 04:00 PM and administered at 06:39 PM. 17Metformin 500 mg- 1 tablet with meals. Scheduled for 04:00 PM and administered at 06:39 PM 18Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 06:39 PM. 19Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 06:40 PM. 20Clobazam 5mg film- 5 mg. Scheduled for 04:00 PM and administered at 09:53 PM. 21Gabapentin 100 mg- 2 capsules. Scheduled for 08:00 PM and administered at 09:32 PM. The morning of 10/26/23 22Gabapentin 300 mg- 1 capsule scheduled for 08:00 AM and administered at 10:03 AM. 23Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 08:00 AM and administered at 10:03 AM. 24(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 25 of 36 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 11/01/2023 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 0755 Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 10:03 AM. Level of Harm - Actual harm 25- Residents Affected - Some Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 10:03AM. 26Clobazam 5 mg film- 5 mg. Scheduled for 08:00 AM and administered at 10:03 AM. 27Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 10:03 AM. The morning of 10/27/23 28Gabapentin 300 mg- 1 capsule scheduled for 08:00 AM and administered at 09:14 AM. 29Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 08:00 AM and administered at 09:14 AM. 30Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 09:14 AM. 31Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 09:14 AM. 32Clobazam 5 mg- 5 mg. Scheduled for 08:00 AM and administered at 09:14 AM. 33Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 09:14 AM. The evening of 10/27/23 34Gabapentin 300 mg- 1 capsule. Scheduled for 04:00 PM and administered at 05:28 PM. 35Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 04:00 PM and administered at 05:29 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 26 of 36 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 11/01/2023 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 0755 36- Level of Harm - Actual harm Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 05:28 PM. Residents Affected - Some 37Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 05:28 PM. The evening of 10/28/23 38Gabapentin 100 mg- 2 capsules. Scheduled for 04:00 PM and administered at 05:50 PM. 39Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 04:00 PM and administered at 05:50 PM. 40Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 05:50 PM. 41Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 05:50 PM. 42Clobazam 10 mg- ½ tablet. Scheduled for 08:00 PM and administered at 09:13 PM The morning of 10/29/23 43Gabapentin 300 mg- 1 capsule scheduled for 08:00 AM and administered at 10:10 AM. 44Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 08:00 AM and administered at 10:11 AM. 45Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 10:11 AM. 46Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 10:10 AM. 47(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 27 of 36 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 11/01/2023 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 0755 Clobazam 5 mg- 5 mg. Scheduled for 08:00 AM and administered at 10:10 AM. Level of Harm - Actual harm 48- Residents Affected - Some Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 10:10 AM. The evening of 10/29/23 49Gabapentin 100 mg- 2 capsules. Scheduled for 04:00 PM and administered at 05:41 PM. 50Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 04:00 PM and administered at 05:44 PM. 51Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 05:41 PM. 52Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 05:48 PM. The evening of 10/30/23 53Clobazam 10 mg- ½ tablet. Scheduled for 08:00 PM and administered at 09:31 PM The evening of 10/31/23 54Gabapentin 100 mg- 2 capsules. Scheduled for 05:00 PM and administered at 08:05 PM. 55Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 04:00 PM and administered at 08:05 PM. 56Apixaban 5 mg- 1 tablet . Scheduled for 04:00 PM and administered at 08:05 PM. 57Lacosamide 200 mg- 1 tablet. Scheduled for 04:00 PM and administered at 08:05 PM. 58(continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 28 of 36 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 11/01/2023 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 0755 Clobazam 10 mg- ½ tablet. Scheduled for 08:00 PM and administered at 09:59 PM Level of Harm - Actual harm 59- Residents Affected - Some Metformin 500 mg- 1 tablet with meals. Scheduled for 04:00 PM and administered at 08:05 PM The morning of 11/01/23 60Gabapentin 100 mg- 2 capsules scheduled for 08:00 AM and administered at 10:03 AM. 61Levetiracetam 1000 mg- 1 ½ tablets. Scheduled for 08:00 AM and administered at 10:03 AM. 62Metformin 500 mg- 1 tablet with meals. Scheduled for 08:00 AM and administered at 10:03 AM. 63Apixaban 5 mg- 1 tablet . Scheduled for 08:00 AM and administered at 10:03 AM. 64Clobazam 5 mg- 5 mg. Scheduled for 08:00 AM and administered at 10:03 AM. 65Lacosamide 200 mg- 1 tablet. Scheduled for 08:00 AM and administered at 10:03 AM. Record review of Review of Resident #1's October Progress Notes revealed, Resident #1's seizure medications were not available upon admission and documentation was as follows: - 10/24/23 AT 5:24 PM signed by LVN B- Clobazam 5 mg Oral Film and Lacosamide 200 mg Tablets were on order. There was no documentation of notifying the NP/MD, Administrator or DON that the medications were unavailable. - 10/24/23 at 09:07 AM signed by LVN B- Clobazam 5 mg Oral Film was on back order. There was no documentation of notifying the NP/MD, Administrator or DON that the medications were unavailable. There was no documentation of notifying the NP/MD, Administrator or DON that medications were unavailable prior to the surveyor notifying the facility of the unavailable medications on 10/24/23 at approximately 4:00 PM. Record review of the facility undated EKit Contents revealed the facility had the following medications: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 29 of 36 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 11/01/2023 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 0755 - 4 tablets of Donepezil 5 mg. Level of Harm - Actual harm - 4 capsules of Gabapentin 100 mg Residents Affected - Some - 4 tablets of Levetiracetam - 4 tablets of Metformin Record review of Resident #1's Individual Control Drug Records revealed, the facility received Clobazam 10 mg tablets for Resident #1 on 10/25/23 and nursing staff retrieved and administered the following doses: - 10/25/23 ½ tablet at 09:58 PM administered by LVN A - 10/26/23 ½ tablet at 10 AM administered by LVN B An observation and interview on 10/25/23 at 09:40 AM revealed, Resident #1 lying in bed, well dressed, well fed in no immediate distress. She said when she admitted 2 days ago her pain medications were not available as well as some other medications on her med list. Resident #1 said when she arrived at the facility she had pain at 10 out 10 and it was so bad she could not sleep but the facility did not administer her Gabapentin because her medication had not arrived yet. Resident #1 said she was currently experiencing pain and needle pain in both her feet but she could not provide a pain scale. In an interview on 10/25/23 at 09:45 AM, the Surveyor notified LVN B, that Resident #1 was reporting pain in her feet. She said she had just administered Gabapentin to Resident #1 and the resident did not report pain. LVN B said she would assess Resident #1 for pain again. In an interview on 10/25/23 at 03:33 PM, the IP said she had not heard anything about Resident #1's seizure medications being on backorder and medications should be started based on the orders on the hospital discharge records. She said Resident #1's admitted nurse should have addressed the residents pain by administering her ordered Gabapentin stat and failure to administer medications as ordered could result in uncontrolled pain and an increased risk of seizures. In an interview on 10/25/23 at 04:50 PM, the IP said she nor the DON were notified of any delays in the receiving or administration of Resident #1's seizure meds. She said she did not know the resident's Clobazam was not available, or there were delays receiving her Lacosamide. In an interview on 10/25/23 at 05:14 PM, the Surveyor notified the DON and Administrator that Resident #1's medication was unavailable and on back order. The DON and Administrator said they were never informed by nursing staff about any availability issues with Resident #1's seizure meds and they would immediately talk to the NP to get an alternative. They said failure to receive seizure medications as orders placed residents at risk of seizures. In an interview on 10/25/23 at 05:35 PM, the DON said that NP B was calling in an alternative to Resident #1's Clobazam and that the resident's Lacosamide was delayed due the provider sending in a late eScript. In an interview on 10/26/23 at 09:25 AM, the pharmacist said, the facility first received an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 30 of 36 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 11/01/2023 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 0755 Level of Harm - Actual harm eScript for Lacosamide 200 mg for Resident #1 on 10/24/23 at 01:09 PM and NP B verbally called in a prescription for Clobazam 10 mg on 10/25/23 at 05:30 PM. He said NP B sent in a prescription for Clobazam 5 mg Film and not tablets on 10/24/23 at 07:00 PM but that medication has been unavailable due to manufacturer production issues for a prolonged period of time so it would not be available, Residents Affected - Some In an interview on 10/26/23 at 10:22 PM, NP B said she was not Resident #1's admitting NP and that she was first notified of Clobazam being unavailable for Resident #1 in the evening of 10/25/23. She said she saw the patient on Tuesday 10/24/23 but did not receive any notifications of medication availability issues until Wednesday 10/25/23. NP B said when a resident admits after 6 PM nursing staff is expected to call in the medication with the on-call provider. She said she was not aware that Resident #1 discharge orders were for ½ of the 10 mg tablets and never for the film. NP B said she expects medications should be ordered and next doses administered pursuant to the hospital discharge orders. NP said prior to the evening of 10/25/23 she was not notified that Resident #1 did not receive any seizure meds (Levetiracetam, Lacosamide, Clobazam) on the evening of her admission, Lacosamide and Clobazam on 10/24/23 and the Clobazam on the morning of 10/25/23. She said once she was notified of the issues with the Clobazam she immediately called in a prescription to the pharmacy for a 3 days' supply of Clobazam 10 mg tablets. She said the resident received her first dose of the tablets were on the evening of 10/25/23. NP B said she expected nursing staff to notify her of any mediation availability issues immediately so she could place an order for an alternative and the pharmacy could do a stat delivery. NP B said failure to administer medications like Levetiracetam, Clobazam and Lacosamide placed residents at risk for seizures. She said she saw Resident Tuesday, 10/24/23, and the resident complained of pain on her big toe so she prescribed Tylenol as needed, but she was never informed that the resident complained of pain or the facility failing to administer her Gabapentin on admission when the resident reported pain at 10 out of 10. NP B said she expected nursing staff to have administered Gabapentin to Resident #1 upon admission if she reported pain at 10 out 10, she believed the medication was available in the EKit, and that she should have been notified of the resident's pain. She said on 10/25/23 she saw the resident to follow up on her seizure and pain medications and the resident complained of bilateral intermittent pain in her feet so she started Resident #1 on Tylenol #3 (a controlled substance used to treat pain) and increased her dose of Gabapentin. NP B said nursing staff should have notified her of Resident #1's continued pain. In an interview on 10/26/23 at 10;40 AM, LVN A said she was the admitting nurse for Resident #1 on 10/23/23. She said when a new resident is admitting the facility the nurse gets a verbal report from the discharging facility before the resident arrives and once the resident arrive they receive the discharge packet. LVN A said the residents medications are verified with the NP from the discharge packet and the medications are started based on the documented next dose. She said she could not remember when she entered Resident #1's medication to start but the resident reported pain at 10 out of 10 so she gave her Gabapentin and received/administered an order for Tylenol but she did not document it in the MAR or EMR. LVN A said Resident #1 said her feet were hurting really bad so she contacted NP A who gave her verbal orders for Tylenol but she never documented the order in the chart. When asked if Resident #1 continued to have pain after admission she said she honestly, didn't remember. NP A said she did not go back to check on the resident until 9/10 PM and she did not call the NP to follow up on Resident #1's pain. LVN A said nursing staff are expected to follow up with the provider for issues regarding pain or medications but it was too busy that night. LVN A said she couldn't say Resident #1's Levetiracetam or other seizure meds were on her mid when she talked to the NP and she would not know if the medication was in the EKit or not. She said she did not realize that she entered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 31 of 36 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 11/01/2023 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 0755 Level of Harm - Actual harm Residents Affected - Some Resident #1's Clobazam as a film instead of tablets and she said failure to enter medications/administer medications as ordered could place residents at risk of continued/uncontrolled pain, seizures, medication error, adverse reactions and unavailability of medications. In an interview on 10/26/23 at 01:30 PM, NP A said she was the admitting nurse for Resident #1 on 10/23/23. She said LVN A called her and read the resident's hospital discharge medications to her and she gave an order to start all medications as listed in the discharge record. NP A said she did not make any changes to Resident #1's medication order included formulations to be administered or start times. She said she expected Resident #1's medications to be started according to the next dose due as listed on the hospital record. NP A said she did not give LVN A instructions to change from Clobazam tablets to Clobazam film and LVN A never reported that Resident #1 was experiencing pain at 10 out 10 upon admission. She said she expected LVN A to administer Gabapentin to the resident as ordered if she experienced pain, she said she did not order any additional pain medications because she was not aware the resident was reporting pain, and she expected to be notified if the resident was having pain so she could take appropriate action. NP A said she was not aware nor was she informed that Lacosamide and Clobazam were controlled substances required an eScript so she did not send a prescription to the pharmacy. NP A said she remembers this specifically because LVN A was concerned about Resident #1 receiving her Zolpidem (a controlled substance used for sleep) so she made sure to notify the MD to send the prescription. NP A said Resident #1 attending physician was changed immediately after admission so she was no longer her provider, but she said failure to administer medications as orders could place Resident #1 at risk for continued/irretractable pain and seizures. In an interview on 10/31/23 at 12:13 PM, the IP said the facility never administered the Clobazam 5 mg film to Resident #1 just the 10 mg pills. In an interview on 11/01/23 at 12:10 PM, LVN A said Resident #1 had just received a brand new order for Donepezil on 10/31/23 so she did not received it on the night of 10/31/23 because it was not available. LVN A said she did not know that Donepezil was available in the EKit. She said there was a list of medications that could be dispensed from the EKit but she does not believe she checked. LVN A said she started working with the facility in January of 2023 and she was never really trained on using the EKit, or admission medication reconciliation and she just learned on her own. She said failure to administer medication as ordered could place residents at risk for untreated health conditions. CR #1 Record review of CR #1's Face Sheet dated 10/25/23 at 11:42 AM revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: femur fracture and an encounter for orthopedic aftercare. The resident discharged to the hospital on [DATE] and never returned to the facility. Record review of CR #1's MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 01 out of 15. Record review of CR #1's admission assessment dated [DATE] and signed by LVN C revealed, CR #1 admitted to the facility on [DATE] at 10:22 PM, reported pain to her left knee at a level of 05 out of 10 and the resident had a surgical incision site as well as open area/wound. Record review of CR #1's Pain Level Summary dated 08/02/23 at 10:27 PM revealed, CR #1 reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 32 of 36 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 11/01/2023 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 0755 pain at 05 out of 10, Level of Harm - Actual harm Record review of CR #1's Physician Order dated 08/03/23 at 01:05 AM revealed Tramadol (pain medication) 50 mg- 1 tablet every 6 hours as needed for moderate and severe pain. Residents Affected - Some Record review of CR #1's August MAR revealed, CR #1 did not receive Tramadol 50 mg upon admission from 08/02/23-08/05/23. In an interview on 10/25/23 at 02:15 PM, Family Member #1 said the resident admitted to the facility in August after surgery. She said the resident was in pain and the facility did not administer the resident's pain medications. She said when she visited her mother on 08/05/23 she was in severe pain when she tried to reposition her. In an interview on 10/31/23 at 04:54 PM, LVN C said she did not remember CR #1. In an interview on 11/01/23 at 01:40 PM, the DON said upon admission nursing staff are expected to reconcile the resident's medications with the provider, ensuring the medication is correct (including the formulation) and matches the discharge orders. He said medications are to be started based on the documented next dose in the discharge orders and if a medication is unavailable it should be retrieved from the EKit or the prescriber should be notified of medication unavailability and an alternative therapy should be requested. The DON said the pharmacy can provide a STAT order which can be delivered within a few orders for critical medications. He said once medications are available for a new admission they should be administered as ordered+/- 1 hr. of its scheduled time and failure to administer medications as ordered could place residents at risk for increased/uncontrolled pain, increased seizure risk and adverse reactions. The DON said prior to medication administration nurses need to ensure that the medication to be administered matches the order down to the formulation ( film vs. tablet) and any discrepancies should be addressed prior to medication administration. The DON said nurses are expected to document accurately and timely and failure to document accurately placed resident at risk of incorrect documentation missed diagnoses, delay in care and overdose. Record review of LVN C's undated training record revealed, LVN C had not attempted her training on Pain Assessment and Management that was assigned on 12/15/22 and there was no documented assigned training on Skin Care and Wound Care. Record review of the facility provided pharmacy Quick Reference document with no revision date revealed, If you place a new order after the daily cut-off times, and the medication is not in your EDK, fax the order and CALL the pharmacy to the inform them of the new order and when the resident will need the medication. New admissions, critical need medications are always available even after hours, CALL the pharmacy. Ordering [NAME]: Monday-Friday the cut off time for new medication orders and new admissions medications was 6:00 PM. All SNF facilities have the potential for 2 deliveries per day- leaving the pharmacy at 01:00 PM and 08:00 PM release times. Any new order must be received by the pharmacy 2 hours prior to the delivery release time and any critical medication-please call the pharmacy. Record review of the facility policy titled Medication Shortages/Unavailable Medication revised 01/01/22 revealed,2- If a medication is unavailable during normal pharmacy hours. 2.2- If the next available delivery causes delay or missed dose in the resident's medication schedule, facility nurse should obtain the medication from the emergency medication supply to administer the dose. 2.3- If the medication is not available in the emergency medication supply, facility staff should notify pharmacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 33 of 36 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 11/01/2023 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 0755 Level of Harm - Actual harm Residents Affected - Some and arrange for an emergency delivery, if necessary. 5- If the medication is unavailable from Pharmacy or a third party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate Physician/Prescriber orders, as necessary. When the pharmacy notifies the facility that a medication is unavailable due to a recall or manufacturer issue, facility staff should notify the physician/prescriber for a new order. 9-when a missed dose is unavoidable, facility nurse should document the missed dose and the explanation such documentation should include: a description of the circumstance of the medication shortage, a description of pharmacy's response upon notification and actions taken. Record review of the facility policy Medication Administration Times revised 01/01/22 revealed, 2- Facility should commence medication administration within 60 minutes before the designated times of administration and should be completed by 60 minutes after the designated times of administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 34 of 36 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 11/01/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 6 residents (Resident #1) whose records were reviewed for accuracy and completeness. - The facility failed to document medication administration to Resident #1 accurately by documenting administration of Clobazam 5 mg film when 10 mg tablets were given. These failures could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings included: Record review of Resident #1's Face Sheet dated 11/01/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: unspecified convulsion, type 2 diabetes, neuropathy (nerve pain), heart failure and high cholesterol. Record review of Resident #1's admission MDS dated [DATE] and printed on 11/01/22 at 09:22 AM revealed, intact cognition as indicated by a BIMS score of 13 out of 15. Record review of Resident #1's Baseline Care Plan dated 10/23/23 revealed, Focus: pain, goal- resident will express pain relief, interventions- pain meds as ordered and evaluate the effectiveness of pain interventions. Record review of Resident #1's Hospital Discharge Instructions dated 10/23/23 at 12:54 PM revealed, Resident #1 discharged with orders for Clobazam (a benzodiazepine controlled substance used to treat seizures) 10mg, ½ tablet by mouth twice a day. Record review of Resident #1's Progress Notes dated 10/25/23 at 09:51 PM and signed by LVN A revealed. clobazam 5mg tablets just arrived from pharmacy NP verbal order per DON to give when it arrived. Record review of Resident #1's Pharmacy Records dated 10/30/23 revealed, - An electronic prescription for Clobazam 5 mg film (a backordered product) instead of Clobazam 10 mg tablets as ordered on the hospital discharge records was first sent to the pharmacy on 10/24/23 at 07:01 PM. Record review of Resident #1's Order Summary dated 10/31/23 at 12:38 PM revealed, - Clobazam 10 mg- give ½ tablet by mouth 2 times a day- ordered on 10/26/23 Record review of Resident #1's Medication Audit Report dated 11/01/23 at 01:27 PM revealed, Resident #1 received Clobazam 5mg- scheduled for 04:00 PM and administered at 09:53 PM; and Clobazam 5 mg for 08:00 AM and administered at 10:03 AM. Record review of Resident #1's October MAR revealed, Resident #1 was administered Clobazam 5 mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 35 of 36 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 11/01/2023 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 0842 Film on the following days when the medication was not available: Level of Harm - Minimal harm or potential for actual harm 10/25/23 scheduled for the 4:00 PM evening dose. 10/26/23 scheduled for the 8:00 AM morning dose. Residents Affected - Few Record review of Resident #1's Individual Control Drug Records revealed, the facility received Clobazam 10 mg tablets for Resident #1 on 10/25/23 and nursing staff retrieved and administered the following doses: 10/25/23 ½ tablet at 09:58 PM administered by LVN A 10/26/23 ½ tablet at 10 AM administered by LVN B An observation and interview on 10/25/23 at 09:40 AM revealed, Resident #1 lying in bed, well dressed, well fed in no immediate distress. She said when she admitted 2 days ago her pain medications were not available as well as some other medications on her med list. In an interview on 10/26/23 at 10:22 PM, NP B said once she was notified of the issues with the Clobazam on 10/25/23 she immediately called in a prescription to the pharmacy for a 3 days' supply of Clobazam 10 mg tablets. She said the resident received her first dose on the evening of 10/25/23. In an interview on 10/31/23 at 12:13 PM, the IP said the facility never administered the Clobazam 5 mg film to Resident #1 just the 10 mg pills. In an interview on 11/01/23 at 01:40 PM, the DON said prior to medication administration nurses need to ensure that the medication to be administered matches the order down to the formulation ( film vs. tablet) and any discrepancies should be addressed prior to medication administration. The DON said nurses are expected to document accurately and timely and failure to document accurately placed resident at risk of incorrect documentation missed diagnoses, delay in care and overdose. Record review of the facility policy titled Nursing Documentation revised 08/10/23 revealed, The medical record must contain an accurate representation of the resident and include enough information to provide a picture of the resident's progress . objectives and/or interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675671 If continuation sheet Page 36 of 36