Health inspection·June 15, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few environment: 4- Explain all procedures and Treatments, Medications , Results of labs/tests , Condition , All changes , Rules , Options. Monitor/document resident's feelings relative to isolation, unhappiness, anger. 5Observe for side effects and adverse reactions of psychoactive medication: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person . Record review of CR'#1's clinical record revealed no discharge orders and no documentation of where she was discharged to , why and when she was discharged from the facility. Record review of CR #1's clinical record revealed a note titled Administrative Note dated 02/13/2023 1:08PM read in part- Had a care conference/IDT meeting with Physician on 2/13/2023 per telephone. DON, ADON, SSD, and Administrator was on the phone with physician. IDT team determined to suggest behavioral hospital may help resident. Also, to speak to psychiatrist to reach out to collaboration physician to receive more feedback for facility. In an interview with the facility's Social Service Director on 06/14/2023 at 11:20AM, she said CR#1 was discharge to a personal care home. She said CR #1 was having behavioral problem and was sent to a local psychiatric hospital. She described CR#1's behavior was talking to herself, walking around the facility, and talking to other residents not to take their medication. She said CR#1 was not hurting herself and not hurting anyone. She said the behavior on 02/13/23 was her usual behavior. She said CR#1 was discharge from the hospital to an assisted living. She said the assistant living was a licensed facility. She provided the name and phone # to a local assisted living facility. She said she verify verified and the facility was a licensed facility During an interview with the DON on 06/14/2023 at 2:00PM, she said she was out sick during the time of CR #1's discharged but remember being called about the resident's behavior. She said there was no documentation of when and how and where CR # 1 was sent out, but her understanding was that CR #1's physician gave the facility a phone # to the county sheriff department. The DON said the sheriff department was called due to resident's behavior of fast walking and speaking to herself and refusing her medication stating that someone was trying to kill her. The DON said she was told that the sheriff came and transfer CR # 1 to a local psychiatric hospital. The DON said the psychiatric hospital send sent CR#1 to an assisted living facility and it was her understanding that the facility was a licensed facility. The DON said she would have an in-service with staff on documentation. The DON said her expectation would be to document all activity that included CR #1's behavior, what lead to calling the sheriff department, any attempt made to assist CR#1, who took CR #1 out of the facility, to where and when. She said all information should have been documented. She said she would have an in-service with all staff. She said the nurse on duty during the time of the incident was an agency nurse. During an interview with the Facility Administrator on 06/14/2023 at 2:40PM, he said the facility did not take the CR#1 back because CR#1 was her own responsible party and the facility wanted CR # 1 to get a legal guardian before being admitted back to the facility. He said CR #1 had always wanted to go to an independent living and the facility was in the process of assisting her to get into an independent living. He said he expect to see documentation on CR #1's clinical records and was not sure who was on duty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Phoenix Post-Acute 519 Ninth Ave N Texas City, TX 77590 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 0622 Level of Harm - Minimal harm or potential for actual harm during the time of the incident. He said CR #1's physician had an emergency and may not be reachable on 06/15/2023. He provided a number to the NP that works with CR #1's physician. A phone call was made to the NP on 06/15/2023 at 2:40PM no answer message was left with a returned phone # . Residents Affected - Few Phone call was made to CR#1's physician on 06/15/23 at 2:43PM. No answer; a message was left. During a phone conversation with the sheriff department on 06/15/2023 at 3:30PM, the Sheriff department said their function was to respond to calls from the community and assist individuals in need of assistance. She said if the resident was in crisis, they will transfer the resident to the psychiatric hospital or hospital. She said in this case the resident might have been transferred to a psychiatric hospital. She looked up resident's information and said CR #1 was transported to a local psychiatric hospital. Record review of the Facility's policy titled Criteria for Transfer and Discharge read in part: It is the policy of the facility that each resident will remain in the facility and not transfer or discharge unless the discharge or transfer is appropriate as per the existing criterial . When the facility transfers or discharge a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and the appropriate information is communicated to the receiving health care institution or provide. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Phoenix Post-Acute 519 Ninth Ave N Texas City, TX 77590 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 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed provide and document sufficient preparation and orientation for one of three (CR #1) records reviewed for safe and orderly transfer or discharge . Residents Affected - Few The facility did not provide or document adequate and sufficient preparation and orientation for one of 3 (CR #1) closed records reviewed for prope and orderly discharged to the community. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services, and denying them a voice regarding their treatment plan. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and was discharged on 02/13/2023. Her diagnoses included unspecific psychosis (collection of symptoms that affect the mind and loss of contact with reality) bipolar disorder (a mental disorder that causes extreme mood swings), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms) and anemia (low levels of red blood cells) Record review of CR #1's discharge MDS dated [DATE] revealed returned not anticipated. Discharge destination was to a psychiatric hospital. Record review of CR #1's last Quarterly MDS assessment dated [DATE] reflected a BIMSs Score of 12 indicated she was mildly impaired cognition. Record review of CR #1's comprehensive care plan undated read in part- Potential for a psychosocial well-being problem r/t Illness/Disease schizoaffective disorder , mood disorder, bipolar, psychosis, Ineffective coping. Resident has history of psychosis, grandiose delusions (lose touch with reality). Goal: 1. Will effectively cope with his/her feelings of (SP isolation, unhappiness, anger by the review date. Intervention: 2-Allow time to answer questions and to verbalize feelings perceptions, and fears. assist/encourage/support to set realistic goals. Consult with: Pastoral care, social services , Psych services. Increase communication between resident/family/caregivers about care and living environment: 3 Explain all procedures and Treatments, Medications , Results of labs/tests , Condition , All changes , Rules , Options. Monitor/document resident's feelings relative to isolation, unhappiness, anger. 4 Observe for side effects and adverse reactions of psychoactive medication: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person . Record review of CR # 1's care plan records revealed no evidence of discharge care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Phoenix Post-Acute 519 Ninth Ave N Texas City, TX 77590 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 0624 Level of Harm - Minimal harm or potential for actual harm Record review of CR #1's discharge MDS dated [DATE] revealed returned not anticipated. Discharge destination was to a psychiatric hospital. Record review of CR'#1's clinical record revealed no discharge orders and no documentation of where CR# 1 was discharged to , why and when she was discharged from the facility. Residents Affected - Few Record review of CR #1's clinical record revealed a note titled Administrative Note dated 02/14/2023 1:08PM read in part- Had a care conference/IDT meeting with Physician on 2/14/2023 per telephone. DON, ADON, SSD, and Administrator was on the phone with physician. IDT team determined to suggest behavioral hospital may help resident. Also, to speak to psychiatrist to reach out to collaboration physician to receive more feedback for facility. In an interview with the facility's Social Service Director on 06/14/2023 at 11:20AM, she said CR#1 was discharged to a personal care home. She said CR #1 was having behavioral problem and was sent to a local psychiatric hospital. She said CR#1's behavior was talking to herself, walking around the facility, and talking to other residents not to take their medication. She said CR#1 was not hurting herself and not hurting anyone. She said that was her usual behavior. She said CR#1 was discharged from the hospital to an assisted living facility that she provided to the hospital. She said the assistant living was a licensed facility. She said provided the name and phone # of the assisted living facility. During an interview with the DON on 06/14/2023 at 2:00PM, she said she was out sick during the time of CR #1's discharged but remember being called about resident's behavior. She said there was no documentation of when and how CR # 1 was sent out, but her understanding was that CR #1's physician gave the facility a phone # to the county sheriff department. She said the sheriff department was called due to resident's behavior of fast walking and speaking to herself and refusing her medication that someone was trying to kill her. The DON said her understanding when she came back was that CR #1's Physician gave the facility a phone # to the sheriff department to call if CR #1 was in crisis. The DON said the facility called the sheriff who came and transferred CR # 1 to a psychiatric hospital. She said the psychiatric hospital sent CR#1 to an assisted living facility and it was her understanding that the facility was a licensed facility that was recommended by the Social Service Director . She said her expectation was to document all information in resident's clinical records why she\he was being transferred by whom, when and to where. She said there should be an order from the attending physician. During an interview with the Facility Administrator on 06/13/2023 at 2:40Pm, he said the facility did not take CR#1 back because CR#1 was her own responsible party and the facility wanted CR # 1 to get a legal guardian before being admitted back to the facility. He said CR #1 had always wanted to go to an independent living and the facility was in the process of assisting her to get into an independent living. He said he expect all information about resident's medical condition to be in their clinical records. He said CR #1's physician had an emergency and may not be reachable. He provided a number for the NP that work with CR #1's physician. A phone call was made to the NP on 06/15/2023 at 2:50PM; there was no answer. A message was left with a returned phone number. A Phone call was made to the Assistant Assisted living facility provided by the facility on 06/15/2023 at 3:50PM. There was no answer. A message was left with a returned phone number. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Phoenix Post-Acute 519 Ninth Ave N Texas City, TX 77590 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 0624 Level of Harm - Minimal harm or potential for actual harm Record review of HHS web site for active assistant Assisted living facility and Nursing homes revealed the name of the facility provided by the social Service Director did not appear as a licensed facility in the directory. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Phoenix Post-Acute 519 Ninth Ave N Texas City, TX 77590 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 interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of three ( CR #1) records reviewed for documentation The facility failed to document in CR # 1 clinical records, how, when and where she was sent\discharged to. This failure places all could place residents at the facility at risk of their records being incomplete and inaccurately documented. being sent out without documentation and at risk of not knowing where they are. Findings include: Record review of CR #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and was discharged on 02/13/2023. Her diagnoses included unspecific psychosis (collection of symptoms that affect the mind and loss of contact with reality) bipolar disorder ( a mental disorder that causes extreme mood swings), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms) and anemia (low levels of red blood cells) Record review of CR #1's clinical record, reflected no documentation of how, when and where she was sent to. Record review reflected the last documented notes in CR #1's clinical record read in partRecord review of CR #1's clinical record revealed a note titled Administrative Note dated 02/13/2023 1:08PM read in part- Had a care conference/IDT meeting with Physician on 2/13/2023 per telephone. DON, ADON, SSD, and Administrator was on the phone with physician. IDT team determined to suggest behavioral hospital may help resident. Also, to speak to psychiatrist to reach out to collaboration physician to receive more feedback for facility. During an interview with the DON on 06/14/2023 at 2:00PM, she said she was out sick during the time of CR #1's discharged but remember being called about resident's behavior. She said there was no documentation of when and how CR # 1 was sent out, but her understanding was that CR #1's physician gave the facility a phone # to the county sheriff department. She said the sheriff department was called due to resident's behavior of fast walking and speaking to herself and refusing her medication that someone was trying to kill her. She said the sheriff came and transferred CR # 1 to a psychiatric hospital. The DON said the psychiatric hospital send sent CR#1 to an assisted living facility that was recommended by the Social Service Director. She said it was her understanding that the facility was a licensed facility. The DON said she would have an in-service with staff on documentation. She said all information should have been documented. She said she does not know how CR # 1 left the facility. During an interview with the Facility Administrator on 06/13/2023 at 2:40Pm, he said the facility did not take CR#1 back because CR#1 was her own responsible party and the facility wanted CR # 1 to get a legal guardian before being admitted back to the facility. He said he expect all information about resident's medical condition to be in their clinical records. Record review of the Facility's policy titled Criteria for Transfer and Discharge read in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Phoenix Post-Acute 519 Ninth Ave N Texas City, TX 77590 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 It is the policy of the facility that each resident will remain in the facility and not transfer or discharge unless the discharge or transfer is appropriate as per the existing criterial . When the facility transfers or discharge a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and the appropriate information is communicated to the receiving health care institution or provide. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Phoenix Post-Acute 519 Ninth Ave N Texas City, TX 77590 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for one (RM 319) of 6 rooms observed in the third floor reviewed for environment. The facility failed to ensure that the floors and walls in room [ROOM NUMBER] were in good repair . This failure could affect all residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: An observation on 06/14/2023 at 2:00PM, of RM [ROOM NUMBER] revealed the ceiling on the right-hand side had an opening estimated about 24 by 24 Square feet and approximately 14-inches wide from the floor to the ceiling section of drywall, was removed from the wall and several scratches in the drywall by the hand washing sink on the right side of the room. Observation also revealed exposed building pipes and wirings . On the floor were pieces of sheet rocks against the wall. Observation of the bathroom revealed there was no light in the bathroom. The light was not visible when turned on. Observation revealed Resident #2 was in B bed awake watching television she was alert and oriented but was not communicative due to dysphasia (a condition that affects the ability to speak or express self) . Attempt was made to have an interview with Resident #2 on 06/14/2023 at 2:00PM but was unable to explain. She put her responsible party on the phone. An interview on 06/14/2023 at 2:05PM, Resident # 2's responsible party said the room had been like that for some times about two to three months ago (since March). She said at first there was no water coming to the room and she complained to the administrator several times. She said since the facility repaired the water, the wall has been open from the ceiling blowing everything on Resident #2's face and food. The RP said she had asked for the wall to be repaired several times and no one seems to care about it. Observation and interview with the facility's Administrator on 06/15/23 at 9:30AM, he looked at the wall and said that was his first time of seeing the wall and he would take care of it. The Administrator pick some of the sheet rocks up from the floor and said, this is my first time seeing this He said he would tell the facility maintenance Director to take care of it During an interview on 06/15/2023 at 10:00AM. LVN B said the wall has been like that for a while . She said the facility was aware of the wall being open. During an interview with CNAs D on 06/15/2023 at 11:00 PM , she said the wall had been like that for a while. She said she does not remember the exact date and time but for a while and the facility was aware of it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Phoenix Post-Acute 519 Ninth Ave N Texas City, TX 77590 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 0921 Level of Harm - Minimal harm or potential for actual harm During an interview with the facility's Maintenance Director on 06/15/2023 at 11:00AM, he said the project was given to a contractor who did the repairs . He said he had reached out to them several times and the contractors keep giving excuses. He said he would take care of it. An invoice for the job and facility's policy on clean and comfortable environment was requested. He said he would contact the contractors for the invoice and would ask the administrator for the policy on environment . Residents Affected - Few During an interview with Maintenance Director on 06/15/2023 at 3:00PM, he said he had covered the wall and was waiting on the contractor to send the invoice and the Administrator to give him the policy on facility's maintenance. Facility's policies on repairs and keeping a clean, comfortable environment for residents, staffs, and the public together with the invoice from the contractor was requested from the Administrator on 06/15/2023 at 3:500PM. He said he would try to find the policy and was waiting on the contractors for any invoice. He said he would e-mail it as soon as he gets them. None was provided prior to exit on 06/15/2023 at 4:10PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 10 of 10