Inspection·January 10, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1 ' s progress notes dated 04/27/23, LVN B noted, CNA retrieved a vape pen from this resident at this time. RP was made aware and reminded of the care plan that was recently had. Record review of Resident #1 ' s progress notes dated 04/28/23, LVN B noted, Another vape pen was removed from this resident possession at this time. Phoned RP and notified her. [RP] stated she has not been to the facility since last weekend, and she also say that after our last care plan she will not bring anymore. She believes are vape pens that she has hidden. So this nurse informed her that is she says they were stolen they are in my office. Record review of Resident #1 ' s progress notes dated 09/15/23, LVN D noted, CNA notified this nurse that while resident was outside smoking, resident had her head down and cigarette was burning through her shorts. no burns on skin noted. CNA pushed resident inside. This nurse pushed resident to her room to assess. I had to pick up resident left leg because it was dragging d/t past stroke. Record review of Resident #1's Annual MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated cognitive intactness. Resident #1 required two-person physical assist for transferring, one-person physical assist with bed mobility and toilet use, and required setup help with eating. Further review of the MDS did not reflect whether Resident #1 did or did not use tobacco. Record review of Resident #1's Smoking Evaluation, dated 10/04/23, indicated the resident was independent and does not require supervision to smoke. Further review of the smoking evaluation indicated the resident had no evidence of burn holes noted in clothing or equipment. The Safety Screen also indicated a care plan was used to ensure Resident #1 was safe while smoking. Further review of the evaluation reflected, If all of the answers on the evaluation are yes, the resident is determined to be an independent smoker. If any of the answers on the evaluation are no, the resident is determined to be a dependent smoker. The resident's care plan must include individualized interventions that may be utilized. Record review of Resident #1's care plan, last revised on 10/04/23, reflected she was a smoker and was at risk for injury, but was a safe smoker and did not require an apron. Interventions included performing smoking assessments according to facility policy; educating the resident on the smoking policy; explaining and showing the resident and family designated smoking areas and repeat as necessary; assisting the resident to and from smoking area as needed; and reminding the resident and family all smoking paraphernalia must be kept at the nurse ' s station. The care plan also indicated a revision was made on 03/22/23 to include the Resident #1's history of having a lighter and refusing to give to staff, causing risk for injury however, the care plan reflected no intervention updates on 03/22/23. Further review of the care plan reflected no revisions to include Resident #1 ' s smoking incident which resulted in burnt clothing on 09/15/23. 2. Record review of Resident #2's face sheet, dated 01/16/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Cellulitis (an acute infection of the skin caused by bacteria that enter the skin through a cut, scratch, sting, animal bite, splinter, puncture wound, piercings and tattoos) of the Buttocks; Unspecified open wound (open wound or gunshot wound) of lower back and pelvis without penetration into retroperitoneum (space behind the abdomen); Type 2 Diabetes (long-term medical condition in which the body improperly uses insulin, resulting in unusual blood sugar levels) and, Difficulty in walking. Record review of Resident #2's Quarterly MDS dated [DATE], reflected the resident's BIMS score was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 2 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0656 Level of Harm - Minimal harm or potential for actual harm 14, which indicated cognitive intactness. Resident #2 used a wheelchair and required substantial assistance with taking on/off footwear; moderate assistance with toileting, bathing, and lower body dressing; and supervision or touching assistance with upper body dressing. The resident performed all other ADLs independently. Further review of the MDS did not reveal whether Resident #2 did or did not use tobacco. Residents Affected - Some Record review of Resident #2's care plan, last revised on 01/03/24, reflected he was not a safe smoker, was at risk for injury and did not require an apron. Interventions included educating the resident on the smoking policy; and, explaining and showing the resident and family designated smoking areas and repeat as necessary. Further review indicated the care plan was updated on 01/03/24 to include an incident of noncompliance. The care plan did not reflect specific details of the noncompliance, however, was revised to include the resident required direct supervision while smoking but was noncompliant as an intervention. Record review of Resident #2's electronic health record did not reflect Progress Notes, or any other documentation which indicated the resident had an incident of noncompliance with the smoking policy on 01/03/24. Record review of Resident #2's Smoking Evaluation, dated 08/22/23, did not reflect whether the resident was an independent smoker or safe to smoke. Further review of the smoking evaluation reflected the resident required supervision and for the facility to store his cigarettes and lighter. The evaluation also indicated that a plan of care was used to ensure Resident #2's safety while smoking. 3. Record review of Resident #3's face sheet, dated 01/16/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Hemiplegia (paralysis of partial or total body function on one side of the body) and Hemiparesis (one-sided weakness, but without complete paralysis); Right Elbow Contracture (stiff right elbow with limited range of motion); Cerebral Infarction (necrotic tissue in the brain due to disrupted blood supply and restricted oxygen supply); and, Muscle wasting and atrophy (significant shortening of the muscle fibers and a loss of overall muscle mass). Record review of Resident #3's Quarterly MDS, dated [DATE], reflected the resident's BIMS score was 9, which indicated moderate cognitive impairment. Resident #3 had impairments on both sides of her upper and lower extremities, used a motorized wheelchair, required substantial assistance for toileting and bathing, supervision or touching assistance for all other ADLs , but she ate independently. Further review of the MDS did not reflect whether Resident #3 did or did not use tobacco. Record review of Resident #3's care plan, last revised on 01/03/24, reflected she was a smoker and was at risk for injury, but was a safe smoker and did not require an apron. Interventions included performing smoking assessments according to facility policy; educating the resident on the smoking policy; explaining and showing the resident and family designated smoking areas and repeat as necessary; assisting the resident to and from the smoking area as needed; and reminding the resident and family all smoking paraphernalia must be kept at the nurses ' station; and, did not require direct staff supervision during smoking breaks. The care plan also indicated a revision was made on 11/16/23 which included Resident #3's noncompliance with the smoking contract on 11/15/23. The care plan did not reflect specific details of the noncompliance incident, nor revisions to include interventions after the resident ' s noncompliance on 11/15/23. Resident #3 ' s care plan indicated the resident had an ADL self-care performance deficit related to cognitive impairment, functional limitations in range of motion or decreased mobility and a contracture of the right elbow. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 3 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #3's electronic health record did not reflect progress notes, or any other documentation which indicated the resident had an incident of noncompliance with the smoking policy on 11/15/23. Record review of Resident #3's Smoking Assessment, dated 03/23/23, did not reflect whether the resident had an independent smoker or was safe to smoke. The assessment indicated Resident #3 had cognitive loss, a visual deficit, required supervision and required the facility to store her lighter and cigarettes. The assessment indicated Resident #3 did not have dexterity problems. The Smoking Assessment reflected a care plan was used to ensure Resident #3 was safe while smoking. Record review of Resident #3's Smoking Evaluation, dated 10/04/23, indicated resident was independent and does not require supervision to smoke. The evaluation reflected Resident #3 had cognitive loss, vision sufficient for safe smoking; required supervision and required the facility to store her lighter and cigarettes. The Smoking Evaluation indicated a care plan was used to ensure Resident #3 was safe while smoking. Further review of the evaluation reflected, If all of the answers on the evaluation are yes, the resident is determined to be an independent smoker. If ANY of the answers on the evaluation are no, the resident is determined to be a dependent smoker. The resident's care plan must include individualized interventions that may be utilized. Observation of residents smoking on 01/03/24 at 10:20 AM revealed, no scheduled smoke times posted on the door, or anywhere else near the area inside or outside in the smoking area. Resident #1 was sitting in her wheelchair at a table in the outside area. Resident #1's profile of the right side of her body was facing the door that leads from inside the facility out to the smoking area. Resident #1 was rummaging through cigarette butts inside a tabletop cigarette receptacle. Resident #2 and Resident #3 sat in their wheelchairs diagonally across from Resident #1, near the wall of the facility. Residents #2 and #3 were smoking a cigarette and having a conversation. Resident #2 often looked over in the direction of Resident #1, and either asked if she was okay or attempted to include Resident #1 in the conversation Resident #2 was having with Resident #3. Resident #2 finished his cigarette, wheeled over to and tossed the butt into the Smoker's Pole that sat on the ground, and wheeled back over to the same spot near Resident #3. Resident #1 began wheeling herself backwards. Resident #2 wheeled over to the rear of Resident #1's wheelchair and pushed Resident #1's wheelchair toward the door leading inside the facility. Resident #2 stopped near Resident #1's wheelchair near the door, but with enough space between the door and Resident #1's wheelchair to allow Resident #2 to wheel himself over and hold the door open while still attempting to assist Resident #1 through the doorway and into the facility. Resident #2 let the door close behind Resident #1 and then wheeled back over near Resident #3. Resident #3 finishes her cigarette, then Resident #2 and #3 wheel themselves inside the facility. No staff joined the residents in the smoker's area while they smoked. No staff observed the smoking residents by approaching or standing near the windows looking out into the smoker's area. The smoker's area is at the end of the 400 hall, which is also a hall with occupied resident rooms. The distance between the nurse's station, which is where 400 hall begins, is at least 60 feet away from the windows looking out into the smoker's area. In an interview with Resident #1 on 01/03/24 at 10:38 AM, she said she did not know long she had been at the facility. She said she was a smoker. She said she did not know what time it was and did not know what the facility ' s scheduled smoke times were. She said she knew the facility ' s smoking policies. Resident #1 stopped responding to questions. In an interview with Resident #2 on 01/03/24 at 10:40 AM, he said he had been living at the facility since the summertime. He said Resident #1 needed a lot of help and that was the reason he came (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 4 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some over to help her get back inside the building. He said he tried to look out for Resident #1 and so did other residents at the facility. He said one of the aides usually helped Resident #1 go inside and out of the building to smoke. He said the staff that came outside with the smoking materials would light Resident #1 ' s cigarette for her too. He said Resident #1 smoked but did not think she had smoked a cigarette while she was outside a few minutes ago. He said the nurse ' s kept everyone ' s cigarettes and passed them out when they come outside during smoke breaks. He said Resident #1 came outside on her own this morning. He said that staff did not have to be outside for him to smoke cigarettes. He said the staff knew he could handle smoking on his own. He said if he wanted to smoke, he was going to smoke no matter what anyone said. He said if a staff said anything to him about smoking, he would probably cuss them out. He said he did not have any cigarettes nor a lighter with him or in his room. He said he did not recall ever seeing Resident #1 or Resident #3 with their own cigarettes or lighters. Resident #2 refused to answer questions regarding how he and Resident #2 accessed the cigarettes they had just smoked or how he and Resident #2 were able to light the cigarettes. Resident #2 said he was not for sure of the scheduled smoke breaks, but he thought there were four smoke breaks each day. He said he knew what the facility ' s smoking policies were but was told he was safe to smoke. In an interview with Resident #3 on 01/03/24 at 10:40 AM, she said she could not remember how long she had been living at the facility. Resident #3 said she was a smoker. She said Resident #1 was a smoker too. She said she did not know if Resident #1 smoked a cigarette while she was outside earlier. Resident #3 said she did not know where the cigarette she smoked came from and did not remember who lit the cigarette for her. She said staff was not outside with the residents right now, but that the staff did come outside when residents were smoking. She said she did not know what time the smoke breaks were supposed to be. She said she was not sure if she knew all the facility ' s smoking policies. In an interview with the DON on 01/03/24 at 10:58 AM, she said she was not aware residents had been outside smoking cigarettes unsupervised. She said she would have to find out which staff was assigned to overseeing the smoke breaks for the day. She said the residents were aware of the smoking policies, but the residents also knew today was the new administrator ' s first day and a lot of different things were happening at the facility on that day. She said resident ' s violating the smoking policy had recently become a problem. She said management was aware and had been working to address the issue. She said staff knew to remind residents who were noncompliant of the smoking policies and to immediately report the noncompliance to a nurse or the ADON. She said she did not know would have to review electronic health records for Residents #1, #2 and #3 because she could not recall off the top of her head when they were last assessed for safe smoking, if they were care planned for smoking or what their interventions related to smoking were. She said she was not aware of any past smoking incidents involving Resident #1, #2 or #3, but would have to review their electronic health records to be sure. The DON said management would immediately work to address the incident and review other necessary information. In an interview with LVN B on 01/10/24 at 10:00 AM, she said she had worked at the facility as a float nurse during the 6a-2p shift for almost two years. She said the facility had four scheduled smoking times and assigned staff members that take residents outside to smoke. She said she did not know what the scheduled smoking times because she was not one of the staff assigned to any smoking duties. She said even though she did not know the smoking schedule, she still knew what the smoking policies were. She said it is not okay for residents to smoke outside during unapproved times or without an assigned staff present. She said residents are not allowed to have smoking materials. She said the resident's cigarettes were kept in a storage area and passed out during smoke breaks. She said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 5 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assigned staff was responsible for lighting cigarettes. She said if she discovered a resident violating the smoking policy, she would immediately notify the ADON to prevent the situation from becoming a safety issue. She said she had never found a resident violating the policy herself, but had a CNA notify her that a resident was violating the smoking policy. She said the CNA came and told LVN B that the CNA had found a resident smoking unsupervised. She said she could not remember the exact date this occurred, but it had been a few months since the incident. She said the resident involved in the incident was Resident #1. She said the CNA told her Resident #1 was outside smoking and had burned a hole in her pants. She said after the CNA notified her, she returned to the smoking area with the CNA to talk to the resident. She said the CNA made sure the resident's cigarette was put out and thrown away before notifying LVN B about what was going on. LVN B said she knew Resident #1 had violated the smoking policy in the past but did not know anything about the incidents. She said she knew other staff had spoken with the resident in the past about being noncompliant. She said was when she observed Resident #1 that day, she seemed more tired than normal, and saw the hole in the resident ' s pant left from the cigarette. She said she asked the resident if she was hurt or burnt anywhere, and Resident #1 said no. She said she reminded the resident about the smoking policy and told her she could have consequences if she kept violating the policy. She said she had the CNA assist LVN B with getting the resident back to her room. She said they assisted the resident into bed then LVN B performed a head-to-toe assessment to check for injuries, vitals and blood pressure. She said the resident did not have any injuries from the incident with the cigarette, but Resident #1 was having difficulty breathing and was very lethargic. She said she completed a change in condition assessment in the resident's electronic health record and contacted the resident's doctor. She said the doctor gave orders to send the resident out to the hospital. She said she notified the DON and the resident's responsible party and documented the smoking incident in the resident's progress notes. She said she did not know if the resident's care plan was updated after the resident burnt her clothing. She said that was something the charge nurse, ADON or DON probably took care of. In an interview LVN C on 01/10/24 at 10:28 AM, she said she began working as the former MDS Coordinator's assistant in October 2023. She said the former MDS nurse left her position with the facility last week and she had been promoted to the MDS Coordinator position. She said she was responsible for assessing residents and reviewing notes from the nurses to put together care plans for residents. She said she performed assessments for care plans and quarterlies, and assisted with new admissions, discharges and PASSR. LVN C said a resident having a change in condition, being put on or taken off of hospice services, falls and other incidents were all reasons to update a resident's care plan. She said the MDS Coordinator would know when it was necessary to update a resident's care plan during the morning staff meetings. She said during morning meetings the staff discuss the things going on with residents like changes in condition, falls and incidents. She said the MDS Coordinator was typically responsible for making updates to care plans, but other staff had the ability to make changes to care plans. She said updating care plans was a joint effort because the social worker, dietary services, the ADON's and the DON all worked on updating care plans. LVN C said charge nurses assessed smoking residents upon admission and if the residents were safe to smoke, they could do so. She said smoking was something that needed to care planned for smoking residents. She said if a resident had an incident while smoking the resident needed to be re-assessed for safe smoking and have their care plan updated based on the incident and the new assessment. She said a charge nurse or the ADON was responsible for doing smoking assessments. LVN C said she did not know why Resident #1's care plan was not updated after the resident had an incident with burning her clothes. She said the incident took place before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 6 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she began working for the facility. She said she was not aware of Resident #1's incident or history of noncompliance with the facility's smoking policies. She said the former MDS nurse left her position with the facility last week and she had been was promoted to the MDS Coordinator position. She said she was responsible for assessing residents and reviewing notes from the nurses to put together care plans for residents. She said she performed assessments for care plans and quarterlies, and assisted with new admissions, discharges and PASSR. LVN C said a resident having a change in condition, being put on or taken off of hospice services, falls and other incidents were all reasons to update a resident's care plan. She said the MDS Coordinator would know when it was necessary to update a resident's care plan during the morning staff meetings. She said during morning meetings the staff discussed the things going on with residents like changes in condition, falls and incidents. She said the MDS Coordinator was typically responsible for making updates to care plans, but other staff had the ability to make changes to care plans. She said updating care plans was a joint effort because the social worker, dietary services, the ADON's and the DON all worked on updating care plans. In an interview with ADON B on 01/10/24 at 12:35 PM, she said the MDS Coordinator, ADONs and the DON were all responsible for working on resident care plans. She said even though ADONs and the DON completed care plans, the MDS Coordinator was responsible for verifying the accuracy of all resident care plans, so it was a team effort. ADON B said smoking evaluations should be completed for residents on admission, on a quarterly basis and if a resident showed signs of a decline. She said she was not aware Residents #1 and #2 were smoking unsupervised on 01/03/24. She said she did not know exact dates of the last smoking evaluations for Residents #1, #2 and #3. ADON B said she did not know whether the residents were considered safe smokers and would have to look at the residents' charts. ADON B said she was sure Residents #1, #2 and #3 were care planned for smoking but was not aware of each of their interventions. She said again, she would have to review their charts. ADON B said she did not recall any incidents of Resident #1 being noncompliant with smoking policies. She said she did not recall an incident that resulted in Resident #1 burning her clothes. ADON B said Resident #1 should have been reassessed for safe smoking by a nurse after burning her clothes but did not know whether this was done. She said Resident #1's care plan should have also been updated after the incident by the MDS Coordinator. She said prior to 12/6/23, the MDS Coordinator was solely responsible for updating resident care plans, so she stayed out of dealing with them. ADON B said if the incident occurred before then, she would not have known whether Resident #1's care plan was updated afterwards. She said smoking residents were at risk of not receiving appropriate care from facility staff without accurate and up to date smoking evaluations and care plans. In an interview with the Administrator and DON on 1/10/24 at 1:15 PM, the Administrator said her first day on the job was 01/03/24. She said she was aware of issues with residents being noncompliant with the facility's smoking policies. She said she was already working with the rest of the management team to address the issue. Both the administrator and the DON said they were not aware Resident #1 had an incident that resulted in Resident #1 burning her clothing. The Administrator said a re-assessment for safe smoking, care plan updates and disciplinary action according to the facility's policy all should have taken place after Resident #1 burnt her clothes while smoking. The DON said she began working at the facility in October 2023 and was never made aware the resident had an incident where she burnt her clothing. The DON agreed that Resident #1 should have been re-assessed and had her care plan updated. The Administrator and the DON agreed Resident #1's smoking incident and incidents of residents smoking unsupervised not being care planned put the residents at risk of unmet care needs and at risk of burns or other serious injuries. Record review of the facility policy, revised 02/10/2021, titled, Comprehensive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 7 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Care Plans reflected the following: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being . 6.The objectives will be utilized to monitor the resident ' s progress. Alternative interventions will be documented, as needed Event ID: Facility ID: 675714 If continuation sheet Page 8 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 7 residents (Resident #1, Resident #2, Resident #3) reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #1, Resident #2 and Resident #3 were supervised while smoking during unscheduled smoking hours. This failure could place residents at risk of burns and other serious injuries. Findings include: 1. Record review of Resident #1's face sheet, dated 01/03/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Hemiplegia (paralysis of partial or total body function on one side of the body) and Hemiparesis (one-sided weakness, but without complete paralysis); Cerebral Infarction (necrotic tissue in the brain due to disrupted blood supply and restricted oxygen supply); Right Elbow Contracture and, Muscle wasting and atrophy (significant shortening of the muscle fibers and a loss of overall muscle mass). Record review of Progress Notes in Resident #1's electronic health record reflected on 03/21/23, Social Worker B noted, MSW contacted resident smokers during 930a break to discuss reported noncompliance (ie . vaping in room, lighters/cigarettes being kept in personal belongs), MSW reminded residents of smoking agreement that was previously signed and also guidelines that must be maintained on behalf of resident safety, MSW went on to further discuss residents ' rights as well as extend social services to address any questions that may arise surrounding smoking policy. Record review of Resident #1 ' s progress notes dated 09/15/23 reflected, LVN D noted, CNA notified this nurse that while resident was outside smoking, resident had her head down and cigarette was burning through her shorts . No burns on skin noted. CNA pushed resident inside. This nurse pushed resident to her room to assess. I had to pick up resident left leg because it was dragging d/t past stroke . Record review of Resident #1's Annual MDS, dated [DATE], reflected the resident's BIMS score was 15, which indicated cognitive intactness. Resident #1 required two-person physical assist for transferring, one-person physical assist with bed mobility and toilet use, and required setup help with eating. Further review of the MDS did not reveal whether Resident #1 did or did not use tobacco. Record review of Resident #1's Smoking Evaluation, dated 10/04/23, indicated the resident was independent and does not require supervision to smoke. The resident had no evidence of burn holes noted in clothing or equipment. A care plan was used to ensure Resident #4 was safe while smoking. Further review of the evaluation reflected, If all of the answers on the evaluation are yes, the resident is determined to be an independent smoker. If any of the answers on the evaluation are no, the resident is determined to be a dependent smoker. The resident's care plan must include individualized interventions that may be utilized. Record review of Resident #1's care plan, last revised on 10/04/23, reflected she was a smoker and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 9 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was at risk for injury, but was a safe smoker and did not require an apron. Interventions included performing smoking assessments according to facility policy; educating the resident on the smoking policy; explaining and showing the resident and family designated smoking areas and repeat as necessary; assisting the resident to and from smoking area as needed; and reminding the resident and family all smoking paraphernalia must be kept at the nurses station. The care plan also indicated a revision was made on 03/22/23 to include the Resident #1's history of having a lighter and refusing to give to staff, causing risk for injury however, the care plan reflected no intervention updates on 03/22/23. Further review of the care plan revealed no revisions to include Resident #1 ' s smoking incident which resulted in burnt clothing on 09/15/23 . 2. Record review of Resident #2's face sheet, dated 01/16/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Cellulitis (an acute infection of the skin caused by bacteria that enter the skin through a cut, scratch, sting, animal bite, splinter, puncture wound, piercings and tattoos) of the Buttocks; Unspecified open wound (open wound or gunshot wound) of lower back and pelvis without penetration into retroperitoneum (space behind the abdomen); Type 2 Diabetes (long-term medical condition in which the body improperly uses insulin, resulting in unusual blood sugar levels) and, Difficulty in walking. Record review of Resident #2's Quarterly MDS, dated [DATE], reflected the resident's BIMS score was 14, which indicated cognitive intactness. Resident #2 used a wheelchair and required substantial assistance with taking on/off footwear; moderate assistance with toileting, bathing, and lower body dressing; and supervision or touching assistance with upper body dressing. The resident performed all other ADLs independently. Further review of the MDS did not reflect whether Resident #2 did or did not use tobacco. Record review of Resident #2's care plan, last revised on 01/03/24, reflected he was not a safe smoker, was at risk for injury and did not require an apron. Interventions included educating the resident on the smoking policy; and, explaining and showing the resident and family designated smoking areas and repeat as necessary. Further review indicated the care plan was updated on 01/03/24 to include an incident of noncompliance. The care plan did not reflect specific details of the noncompliance, however, was revised to include the resident required direct supervision while smoking but was noncompliant as an intervention. Record review of Resident #2's electronic health record did not reflect Progress Notes, or any other documentation which indicated the resident had an incident of noncompliance with the smoking policy on 01/03/24. Record review of Resident #2's Smoking Evaluation, dated 08/22/23, did not reflect whether the resident was an independent smoker or safe to smoke. The resident required supervision and the facility to store his cigarettes and lighter. The evaluation also indicated a plan of care was used to ensure Resident #2's safety while smoking. 3. Record review of Resident #3's face sheet, dated 01/16/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Hemiplegia (paralysis of partial or total body function on one side of the body) and Hemiparesis (one-sided weakness, but without complete paralysis); Right Elbow Contracture (stiff right elbow with limited range of motion); Cerebral Infarction (necrotic tissue in the brain due to disrupted blood supply and restricted oxygen supply); and, Muscle wasting and atrophy (significant shortening of the muscle fibers and a loss of overall muscle mass). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 10 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0689 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's Quarterly MDS, dated [DATE], reflected the resident's BIMS score was 9, which indicated moderate cognitive impairment. Resident #3 had impairments on both sides of her upper and lower extremities, used a motorized wheelchair, required substantial assistance for toileting and bathing, supervision or touching assistance for all other ADLs, but she ate independently. Further review of the MDS did not reflect whether Resident #3 did or did not use tobacco. Residents Affected - Some Record review of Resident #3's care plan, last revised on 01/03/24, reflected she was a smoker and was at risk for injury but was a safe smoker and did not require an apron. Interventions included performing smoking assessments according to facility policy; educating the resident on the smoking policy; explaining and showing the resident and family designated smoking areas and repeat as necessary; assisting the resident to and from smoking area as needed; and reminding the resident and family all smoking paraphernalia must be kept at the nurse ' s station; and, did not require direct staff supervision during smoking breaks. The care plan also indicated a revision was made on 11/16/23 to include Resident #3's noncompliance with the smoking contract on 11/15/23. Further review of the care plan did not reflect specific details of the noncompliance incident, nor revisions to include interventions after the resident ' s noncompliance on 11/15/23. Resident #3 ' s care plan also indicated the resident had an ADL self-care performance deficit related to cognitive impairment, functional limitations in range of motion or decreased mobility and a contracture of the right elbow. Record review of Resident #3's electronic health record did not reflect progress notes, or any other documentation which indicated the resident had an incident of noncompliance with the smoking policy on 11/15/23. Record review of Resident #3's Smoking Assessment, dated 03/23/23, did not reflect whether the resident was an independent smoker or safe to smoke. Resident #3 had cognitive loss, a visual deficit, required supervision and required the facility to store her lighter and cigarettes. Resident #3 did not have dexterity problems. The Smoking Assessment also reflected a care plan was used to ensure Resident #3 was safe while smoking. Record review of Resident #3's Smoking Evaluation, dated 10/04/23, indicated resident was independent and does not require supervision to smoke. Resident #3 had cognitive loss, vision sufficient for safe smoking; required supervision and required the facility to store her lighter and cigarettes. The Smoking Evaluation also indicated a care plan was used to ensure Resident #3 was safe while smoking. Further review of the evaluation reflected, If all of the answers on the evaluation are yes, the resident is determined to be an independent smoker. If any of the answers on the evaluation are no, the resident is determined to be a dependent smoker. The resident's care plan must include individualized interventions that may be utilized. Observation of facility smoking area on 01/03/24 at 10:20 AM revealed, no scheduled smoke times posted on the door, or anywhere else near the area inside or outside in the smoking area. Resident #1 was sitting in her wheelchair at a table in the outside area. Resident #1's profile of the right side of her body was facing the door which led from inside the facility out to the smoking area. Resident #1 was rummaging through cigarette butts inside a tabletop cigarette receptacle. Resident #2 and Resident #3 sat in their wheelchairs diagonally across from Resident #1, near the wall of the facility. Residents #2 and #3 were smoking a cigarette and having a conversation. Resident #2 often looked over in the direction of Resident #1, and either asked if she was okay or attempted to include Resident #1 in the conversation Resident #2 was having with Resident #3. Resident #2 finished his cigarette, wheeled over to and tossed the butt into the Smoker's Pole which sat on the ground, and wheeled back over to the same spot near Resident #3. Resident #1 began wheeling herself backwards. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 11 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #2 wheeled over to the rear of Resident #1's wheelchair and pushed Resident #1's wheelchair toward the door leading inside the facility. Resident #2 stopped near Resident #1's wheelchair near the door, but with enough space between the door and Resident #1's wheelchair to allow Resident #2 to wheel himself over and hold the door open while still attempting to assist Resident #1 through the doorway and into the facility. Resident #2 let the door close behind Resident #1 and then wheeled back over near Resident #3. Resident #3 finished her cigarette, then Residents #2 and #3 wheeled themselves inside the facility. No staff joined the residents in the smoker's area while they smoked. No staff observed the smoking residents by approaching or standing near the windows looking out into the smoker's area. The smoker's area was at the end of the 400 hall, which was also a hall with occupied resident rooms. The distance between the nurse's station, which was where 400 hall began, was at least 60 feet away from the windows looking out into the smoker's area. In an interview with Resident #1 on 01/03/24 at 10:38 AM, she said she did not know how long she had been at the facility. She said she was a smoker. She said she did not know what time it was and did not know what the facility ' s scheduled smoke times were. She said she knew the facility ' s smoking policies. Resident #1 stopped responding to questions. In an interview with Resident #2 on 01/03/24 at 10:40 AM, he said he had been living at the facility since the summertime. He said Resident #1 needed a lot of help and was the reason he went over to help her get back inside the building. He said he tried to look out for Resident #1 and so did other residents at the facility. He said one of the aides usually helped Resident #1 go inside and out of the building to smoke. He said the staff who went outside with the smoking materials would light Resident #1 ' s cigarette for her. He said Resident #1 smoked but did not think she had smoked a cigarette while she was outside a few minutes ago. He said the nurse ' s kept everyone ' s cigarettes and passed them out when they went outside during smoke breaks. He said Resident #1 went outside on her own this morning. He said staff did not have to be outside for him to smoke cigarettes. He said the staff knew he could handle smoking on his own. He said if he wanted to smoke, he was going to smoke no matter what anyone said. He said if a staff said anything to him about smoking, he would probably cuss them out. He said he did not have any cigarettes nor a lighter with him or in his room. He said he did not recall ever seeing Resident #1 or Resident #3 with their own cigarettes or lighters. Resident #2 refused to answer questions regarding how he and Resident #2 accessed the cigarettes they had just smoked or how he and Resident #2 were able to light the cigarettes. Resident #2 said he was not for sure of the scheduled smoke breaks, but he thought there were four smoke breaks each day. He said he knew what the facility ' s smoking policies were but was told he was safe to smoke. In an interview with Resident #3 on 01/03/24 at 10:40 AM, she said she could not remember how long she had been living at the facility. Resident #3 said she was a smoker. She said Resident #1 was a smoker too. She said she did not know if Resident #1 smoked a cigarette while she was outside earlier. Resident #3 said she did not know where the cigarette she smoked came from and did not remember who lit the cigarette for her. She said staff were not outside with the residents, but the staff went outside when residents were smoking. She said she did not know what time the smoke breaks were. She said she was not sure if she knew all of the facility ' s smoking policies. In an interview with the DON on 01/03/24 at 10:58 AM, she said she was not aware residents were outside smoking cigarettes unsupervised. She said she would have to find out which staff were assigned to oversee the smoke breaks for the day. She said the residents were aware of the smoking policies, but the residents also knew today was the new administrator ' s first day and a lot of different things were happening at the facility. She said residents who violated the smoking policy had recently become a problem . She said management was aware and was working to address the issue. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 12 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said staff knew to remind residents who were noncompliant of the smoking policies and to immediately report the noncompliance to a nurse or the ADON. She said she did not know who would have to review the electronic health records for Residents #1, #2 and #3 because she could not recall off the top of her head when they were last assessed for safe smoking, if they were care planned for smoking or what their interventions related to smoking were . She said she was not aware of any past smoking incidents which involved Residents #1, #2 or #3, but would have to review their electronic health records to be sure. The DON said management would immediately work to address the incident and review other necessary information . In an interview with LVN B on 01/10/24 at 10:00 AM, she said she had worked at the facility as a float nurse during the 6AM-2PM shift for almost two years. She said the facility had four scheduled smoking times and assigned staff members who took residents outside to smoke. She said she did not know what the scheduled smoking times were because she was not one of the staff assigned to any smoking duties . She said even though she did not know the smoking schedule, she still knew what the smoking policies were. She said it was not okay for residents to smoke outside during unapproved times or without an assigned staff present. She said residents were not allowed to have smoking materials. She said the resident's cigarettes were kept in a storage area and passed out during smoke breaks. She said the assigned staff were responsible for lighting cigarettes. She said if she discovered a resident violating the smoking policy, she would immediately notify the ADON to prevent the situation from becoming a safety issue. She said she never found a resident violating the policy herself, but had a CNA notify her a resident was violating the smoking policy. She said the CNA came and told LVN B the CNA found a resident smoking unsupervised. She said she could not remember the exact date this occurred, or who the CAN was, but it had been a few months since the incident. She said the resident involved in the incident was Resident #1. She said the CNA told her Resident #1 was outside smoking and had burned a hole in her pants. She said after the CNA notified her, she returned to the smoking area with the CNA to talk to the resident. She said the CNA made sure the resident's cigarette was put out and thrown away before notifying LVN B about what was going on. LVN B said she knew Resident #1 had violated the smoking policy in the past but did not know anything about the incidents. She said she knew other staff had spoken with the resident in the past about being noncompliant. She said when she observed Resident #1 that day, she seemed more tired than normal, and saw the hole in the resident ' s pants left from the cigarette. She said she asked the resident if she was hurt or burnt anywhere, and Resident #1 said no. She said she reminded the resident about the smoking policy and told her she could have consequences if she kept violating the policy. She said she had the CNA assist LVN B with getting the resident back to her room. She said they assisted the resident into bed then LVN B performed a head-to-toe assessment to check for injuries, vitals and blood pressure. She said the resident did not have any injuries from the incident with the cigarette, but Resident #1 had difficulty breathing and was very lethargic. She said she completed a change in condition assessment in the resident's electronic health record and contacted the resident's doctor. She said the doctor gave orders to send the resident out to the hospital. She said she notified the DON and the resident's responsible party and documented the smoking incident in the resident's progress notes. She said she did not know if the resident's care plan was updated after the resident burnt her clothing. She said that was something the charge nurse, ADON or DON probably took care of. She said all of the staff knew residents were not supposed to smoke unattended by staff. She said staff also knew incidents with residents smoking were supposed to be immediately reported to the ADON. In an interview with LVN C on 01/10/24 at 10:28 AM, she said she began working as the former MDS Coordinator's assistant in October 2023. LVN C said charge nurses assessed smoking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 13 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents upon admission and if the residents were safe to smoke, they could do so. She said smoking was something that needed to care planned for smoking residents. She said if a resident had an incident while smoking the resident needed to be re-assessed for safe smoking and have their care plan updated based on the incident and the new assessment. She said a charge nurse or the ADON was responsible for doing smoking assessments. LVN C said she did not know why Resident #1's care plan was not updated after the resident had an incident with burning her clothes. She said the incident took place before she began working for the facility. She said she was not aware of Resident #1's incident or history of noncompliance with the facility's smoking policies. LVN C said residents breaking the smoking policy was not uncommon and sometimes a little difficult for staff to manage. She said a lot of the residents were completely independent before living at the facility and wanted to feel like they were being treated like adults. She said both the residents and staff were aware residents were not supposed to smoke unsupervised and only during smoke breaks. She said she could not remember the scheduled smoking break times. She said the staff knew they were supposed to ask the resident to put their cigarette out and then report the incident to the ADON. LVN C said staff tried to abide by asking residents to put their cigarettes out when they were caught being noncompliant, but some residents would become upset, aggressive, and even violent with staff sometimes over being reminded about the smoking policies. She said in those instances or if the staff anticipated behavior like that from a resident being noncompliant, staff knew to immediately report the noncompliance to the ADON. She said even though residents who were noncompliant with the smoking policy knew what the consequences were, but likely chose to continue noncompliant behavior because consequences were not enforced. In an interview with LVN A on 01/10/24 at 11:43 AM, she said the smoking area was located on the back of the 400 hall and residents had scheduled 4 smoke breaks. She said residents were not allowed to smoke outside of those four times. She said it was okay for residents to smoke during unauthorized times if they were accompanied by one of their family members in the smoking area. LVN A said the residents' smoking supplies were kept at Station B in a tackle box and any overflow of supplies were kept in cubbies in the medication room. She said if staff were to catch a resident being noncompliant with the facility's smoking policy, the staff were supposed to have a conversation with the resident and document the incident in a progress note in the resident's electronic health record. In an interview with CNA A on 01/10/24 at 11:56 AM, he said he had worked at the facility for 20 years. He said there were four designated smoke breaks for residents. He said the residents did not always adhere to the smoking times. He said if residents were caught smoking unsupervised or smoking outside of the designated times, staff were supposed to report the information to the nurse. He said if he saw a resident smoking unsupervised, he might say something to the resident, but some of the residents could get verbally aggressive and sometimes violent. He said he did not know why but a lot of the residents got really angry about cigarette smoking. He said whether he said something to the resident or not, he would always call the nurse for everything . In an interview with Med Aide A on 01/10/24 at 12:10 PM, she said she had worked at the facility one year. She said she knew what the facility's smoking policies were for the residents and staff. She said she also was in-serviced on the smoking policies but could not recall when. Med Aide A said all residents had to be supervised if they were smoking. She said if she saw a resident smoking unsupervised, she would immediately notify a nurse. In an interview with LVN D on 01/10/24 at 12:24 PM, she said there was supposed to be a staff member outside with residents whenever they smoked. She said if she saw a resident smoking a cigarette unsupervised, she would ask the resident to put the cigarette out immediately. LVN D said she would re-educate the residents on the policies and put a progress note in the resident ' s (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 14 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0689 chart and notify the ADON and DON. Level of Harm - Minimal harm or potential for actual harm In an interview with ADON B on 01/10/24 at 12:35 PM, she said smoking evaluations should be completed for residents on admission, on a quarterly basis and if a resident showed signs of a decline. She said she was not aware Residents #1 and #2 were smoking unsupervised on 01/03/24. She said she did not know exact dates of the last smoking evaluations for Residents #1, #2 and #3. ADON B said she did not know whether the residents were considered safe smokers and would have to look at the residents' charts. ADON B said she was sure Residents #1, #2 and #3 were care planned for smoking but was not aware of each of their interventions. She said again, she would have to review their charts. She said the residents were aware of the facility's smoking policies and should not have been smoking unsupervised. She said the staff were also aware of the smoking policies. ADON B said if residents were outside smoking unattended or during off hours it was her expectation that staff asked the noncompliant resident to put the cigarette out. She said she knew asking residents to do that could be difficult for staff anticipating certain residents' reactions. ADON B said some residents would use profane language or get aggressive with staff. She said at the very least, the staff were expected to notify management so they could immediately ensure safety for the smoking residents. She said the residents signed smoking agreements when they were admitted to the facility. ADON B said the residents really did not respect the smoking policies because they got reminded of the policies each time, they were noncompliant. She said there were no real consequences beyond reeducation for the residents. She said the residents knew one of the potential risks of violating the smoking policies was being asked to leave the facility. ADON B said she could not recall any incidents of noncompliance with the smoking policies that resulted in a documented disciplinary action or reprimand for any residents since she started working for the facility. She said she thought the residents might not have taken the policies seriously since there had been changes in the administrator's position several times and expectations of each administrator had been different. ADON B said now they had a permanent Administrator who started last week, she was hopeful about improvements with the smoking residents. She said the new Administrator had been made aware that smoking noncompliance was an issue. ADON B said she did not recall any incidents of Resident #1 being noncompliant with smoking policies. She said she did not recall an incident that resulted in Resident #1 burning her clothes. ADON B said Resident #1 should have been reassessed for safe smoking by a nurse after burning her clothes but did not know whether this was done. ADON B said if the incident occurred before then, she would not have known whether Resident #1's care plan was updated afterwards. She said smoking residents were at risk of not receiving appropriate care from facility staff without accurate and up to date smoking evaluations and care plans. ADON B said smoking residents were also at risk of being put in unsafe situations and sustaining injuries when their care plans were not appropriately followed or smoking unsupervised. Residents Affected - Some In an interview with the Administrator and DON on 1/10/24 at 1:15 PM, the Administrator said her first day on the job was 01/03/24. She said she was aware of issues with residents being noncompliant with the facility's smoking policies. She said she was already working with the rest of the management team to address the issue. Both the Administrator and the DON said they were not aware Resident #1 had an incident that resulted in Resident #1 burning her clothing. The Administrator said a re-assessment for safe smoking, care plan updates and disciplinary action according to the facility's policy all should have taken place after Resident #1 burnt her clothes while smoking. The DON said she began working at the facility in October 2023 and was never made aware the resident had an incident where she burnt her clothing. The DON agreed Resident #1 should have been re-assessed and had her care plan updated. The DON said the chair of the smoking policy was the Social Worker. She said the facility had not had a permanent social worker in a while. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 15 of 16 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The DON said the social worker helped to oversee and manage the effectiveness of the smoking policy. She said a permanent social worker had just been hired along with having an administrator in place. The DON said she was confident issues with residents violating the smoking policy would decrease. The DON said the staff had been re-educated on the facility smoking policies since she had started her position as the DON but could not remember the exact date. The Administrator and the DON agreed it was their expectation residents either put their cigarette out or staff remain with the resident until they finished their cigarette when staff found residents smoking unsupervised. The Administrator said she would prefer for the resident to put their cigarette out immediately; however, she understood it might take some time working with the residents to get them to comply with policies. The Administrator and the DON agreed Resident #1's smoking incident and incidents of residents smoking unsupervised put the residents at risk of unmet care needs and at risk of burns or other serious injuries. Record review of the facility ' s, undated, Smoking Agreement for residents reflected the following: .At no time is a resident allowed to have smoking materials of any kind (this includes lighters, cigarette, electronic cigarettes, smokeless tobacco, etc.) in their possession, all smoking materials will be kept by the facility in a central location . Smoking is always supervised by a staff member, at no time shall a resident smoke on the premises without a staff member present .Smoking is only allowed at the designated smoke times .Smoking outside the designated scheduled times may occur if a staff member is present .Periodic evaluation of the resident ' s physical and cognitive status will be completed .Failure to follow this agreement will result in re-education regarding the smoking policy and procedures and could lead to discharge depending upon the severity of incident . By signing the acknowledgment agreement below, you attest that during your stay at the facility: I will not keep any type of smoking materials in my possession .I will not smoke on premises except at designated times at designated location, and with staff present .I understand that I will periodically have an evaluation completed to determine the type of smoking supervision, I may, or may not need .I have received a copy of the facility ' s smoking policy and Smoking Agreement .I understand failure to follow the facility smoking policies may lead to reeducation and or discharge from the facility. Record review of the facility ' s, undated, Smoking Policy Statement reflected the following: 2. Residents and Visitors .This facility will supervise all resident smoking for the safety of all residents and employees .All resident smoking paraphernalia must be checked in with the nurse .Resident smoking paraphernalia will be secured at the nurse ' s station and provided to the resident at specified smoking times .Supervision of smoking residents will be a shared responsibility of all departments . 3. Reporting Violations a. It is the responsibility of all personnel to report smoking violations. Violations should be reported to the employee ' s supervisor as soon as practical. The various supervisors are responsible for enforcing these rules .c. Residents that fail to abide by facility smoking rules will be given a notice of intent to discharge .Scheduled smoking times for residents. Facility will determine smoking times . For your safety, residents are not [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675714 If continuation sheet Page 16 of 16