Inspection·June 16, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some demonstrating any of the behaviors proclaimed by CNA S, therefore she was allowed to remain in the dining room. Resident was very upset and would not communicate other than stating to me that she wants to Stay. A review of Resident #3's care plan dated 05/07/22 that Resident #3 was dependent on staff for activities, cognitive stimulation, social interaction related to Cognitive Deficits, and interventions include inviting resident to activities, caregivers provide opportunity for positive interactions, attention, and socialization, and when reasonable discuss the resident's behaviors. In an interview with LVN G on 06/16/2022 at 5:15 PM revealed that she was the nurse for Resident #3. LVN G stated that Resident #3 was not prohibited from dining with other residents, and she does like to dine in the main dining room with other residents on occasions. LVN G stated that Resident #3 does have behaviors of spitting, however she should be allowed the opportunity to dine with others in her home with positive reinforcement, redirection of negative behaviors and encouragement. A review of facility policy on Resident Rights revealed that all employees shall treat all residents with respect and dignity, self-determination through choices, communication with and access to people and services at the facility, exercise his or her right as a resident at the facility, be informed about rights, voice grievances and be expected to receive response. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 2 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two (Residents #158 and #79) of 17 residents reviewed for accommodation of needs. Residents Affected - Few The facility failed to put Resident #158 and #79's call light within reach. This failure could affect all residents by placing them at risk of not being able to call for help, a delay in receiving care and treatment, and anxiety and fear. Findings included: An observation on 6/14/22 at 10:20 AM revealed Resident #158 was sitting reclined in a chair with her call light on her bed, on furthest side from the resident and behind her. When asked at that time if she could reach the call light, Resident #158 stated, I can't reach it. She also stated she would yell out for help if she needed it and was unable to reach her call light. An observation on 6/14/22 at 10:25 AM revealed Resident #79 was sitting up in bed and his call light was on the floor behind the head of his bed. When asked at the time if he could reach his call light he looked around and said, I don't even know where it is can you see it? When informed where the call light was located Resident #79 stated he could not reach it. He also stated when he can not reach his call light he calls out for help. An observation on 6/15/22 at 9:15 AM revealed Resident #158 sitting reclined in a chair on the far side of her bed and her call light was clipped to the call light cord on the wall. Resident #158's call light was not within her reach. When asked at that time if she could reach the call light, Resident #158 looked around for the call light and said, I can't even see it, where is it? An observation on 6/15/22 at 9:22 AM revealed Resident #79 sleeping in bed and his call light was on the floor behind the head of his bed. Review of Resident #158's electronic health record on 06/16/22 at 4:30 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Dementia without Behavioral Disturbance, Irritable Bowel Syndrome without diarrhea, Dysphagia, Hypertension, Gastro-Esophageal Reflux Disease, and Rheumatoid Arthritis. Review of resident's admission MDS dated [DATE] revealed a BIM's score of 9. Review of Resident #79's electronic health record on 06/16/22 at 4:50 PM, reflected he was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery, Hypertensive Heart Disease without Heart Failure, Pure Hypercholesterolemia, Radiculopathy, Cognitive Communication Deficit, Aphasia, Mixed Hyperlipidemia, Insomnia due to Medical Condition, Unspecified Intellectual Disabilities, Osteoarthritis, Right Ankle and Foot, and Vitamin D Deficiency. Review of resident's annual MDS dated [DATE] revealed a BIM's score of 12. During an interview and observation on 6/15/22 beginning at 2:15 pm with LVN D regarding the location of Resident #158's call light being clipped to call light cord on the wall, he stated the resident's call light is not supposed to be there and that it should always be within reach of the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 3 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few so the resident can call for help if she needs it. LVN D went around Resident 158's bed and removed call light from wall and placed within reach of resident. LVN D stated regarding Resident #79's call light being on the floor behind resident, the resident's call light ends up on the floor behind resident often and staff on this floor know that and are supposed to be checking often to make sure it is within reach and clipped to his pillow. LVN D reached under Resident #79's bed to retrieve call light and clipped call light to resident's pillow. LVN D stated both residents are able to use their call lights. He also stated when staff are making rounds call lights should be checked to make sure they are within reach of residents. During an interview on 06/17/22 at 11:45 AM with the DON, she stated all staff are responsible for making sure residents call lights are within reach and any staff person who enters a resident's room should be making sure call lights are placed within reach. DON stated if call lights are not within reach a resident would not be able to call for help in an emergency or at any time, therefore they need to in within reach at all times. Review of facility policy titled Answering the Call Light, dated March 2012 . Purpose; The purpose of this procedure is to respond to the resident's requests and needs .General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 4 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for four (Residents #49, #77, #209, and #7) of seven residents reviewed for receiving enteral feeding via a pump. The facility failed to clean enteral feeding pumps, which were observed to be dirty on 06/14/22, 06/15/22, and on 06/16/2022 for Residents #49, #77, #209, and #7. The facility failed to clean Resident #5's room, and floor mat which was observed to be dirty on 06/16/22. These failures could affect residents, who received their nutritional needs via an enteral feeding pump, by placing them at risk for spreading disease-causing organisms, cross-contamination and possible infection. This failure could affect residents who rely on the facility to maintain their rooms in a sanitary, orderly, and comfotable manner , by placing them at risk for spreading disease-causing organisms, cross-contamination and possible infection. Findings included: Observation on initial rounds of Resident #49, Resident #77, Resident 209, and Resident #7's enteral feeding pump on 06/14/22 beginning at 10:05 AM and ending at 10:45 AM revealed a light brown colored substance on the front, back, left side, right side, top, and bottom of the pump, up and down the pole, and on the base of the pole. Observation of Resident #49, Resident #77, Resident 209, and Resident #7's enteral feeding pump on 06/15/22 beginning at 9:00 AM and ending at 9:15 AM revealed a light brown colored substance on the front, back, left side, right side, top, and bottom of the pump, up and down the pole, and on the base of the pole. Observation of Resident #49, Resident #77, Resident 209, and Resident #7's enteral feeding pump on 06/16/22 beginning at 8:45 AM and ending at 8:55 AM revealed a light brown colored substance on the front, back, left side, right side, top, and bottom of the pump, up and down the pole, and on the base of the pole. Observation of Resident #5's on 06/16/2022 at 12:30 PM, of room [ROOM NUMBER] C, revealed his bed in a low position with fall mats on both sides of the bed with trash debris, used napkins from the kitchen, bread, red spots on the fall mat to the right approximately 10 splatters. On the left side of the bed was a second fall mat that had splattered liquid spots approximately 5 spots were observed on the fall mat. Review of Resident #49's electronic health record on 06/16/22 at 3:16 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Dementia, Moderate Protein-Calorie Malnutrition, Myelodysplastic Syndrome, Gastrostomy Malfunction, Cognitive Communication Deficit, Gastro-Esophageal Reflux Disease, Adult Failure to Thrive, Chronic Gout, Anorexia, Alzheimer's Disease, Anemia, Dyspnea, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 5 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dysphagia, Oral Phase, Hypothyroidism, Major Depressive Disorder, Mild Cognitive Impairment, Hypertension, and Osteoarthritis. Review of resident's annual MDS dated [DATE] revealed a BIM's score of 4. Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump Jevity 1.2 @ 55ml/hr with water flush 35 ml/hr x 22 hours. Review of Resident #77's electronic health record on 06/16/22 at 3:35 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Occlusion and Stenosis of Unspecified Cerebral Artery, Anemia, Unspecified Protein-Calorie Malnutrition, Dementia without Behavioral Disturbance, Hypertension, Pressure Ulcer of Sacral Region, Stage 4, Osteomyelitis, and Aphasia. Review of resident's quarterly MDS dated [DATE] revealed a BIM's score of 00. Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump Jevity 1.2 @ 55ml/hr with water flush 25 ml/hr x 22 hours. Review of Resident #209's electronic health record on 06/16/22 at 3:50 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Malignant Neoplasm Unspecified Ovary, Anemia, Hyperlipidemia, Polyneuropathy, Metabolic Encephalopathy, Hypertension, Atrial Fibrillation, Peripheral Vascular Disease, Pneumonia, Acute Respiratory Failure with Hypoxia, Gastro-Esophageal Refluz Disease, Chronic Hepatitis, Pressure Ulcer of Sacral Region, Stage 3, Chronic Kidney Disease, and Unspecified Fracture of Right Femur. Review of resident's admission MDS dated [DATE] revealed a BIM's score of 10 . Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump Jevity 1.2 @ 50cc/hr with water flush 35 cc/hr x 23 hours. Review of Resident #7's electronic health record on 06/16/22 at 4:15 PM, reflected she was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Acute and Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes, Pneumonia, Abnormal Weight Loss, Dementia In Other Diseases Classified Elsewhere with Behavioral Disturbance, Esophageal Obstruction, Dysphagia, Oral Phase, Other Reduced Mobility, Osteoporosis, Adult Failure to Thrive, Gastrostomy Status, Hypothyroidism, Vascular Dementia, Bipolar Disorder, Major Depressive Disorder, Gastro-Esophageal Reflux Disease, Insomnia, Unspecified Mononeuropathy of Unspecified Lower Limb, and Hypertension. Review of resident's quarerly MDS dated [DATE] revealed a BIM's score of 01. Review of resident's physician orders regarding residents peg tube feeding rate revealed GT: Pump give glucernia 1.2 @ 55ml/hr cc/hr per GT x 22 hours water flush at 40 ml/hr x 22 hours every shift. During an interview and observation on 06/16/22 at 8:58 AM with LVN A, of the condition of the enteral feeding pumps and pole of residents #49 and #77, LVN A stated, no one has ever told me who is responsible for cleaning them. She stated residents #49 and #77's peg tube pumps and poles looked really bad and I will clean them. LVN A also stated dirty feeding pumps and poles can affect residents by having infection control issues and it is a dignity issue. During an interview and observation on 06/16/22 at 9:12 AM with LVN B, of the condition of the enteral feeding pumps and pole of resident #209, LVN B stated, there was no specific person assigned to cleaning them but anyone that notices it should clean them, either way it falls back on the nurse at some point. LVN B stated regarding dirty feeding pumps and poles, there is always a risk of infection, with anything that is dirty, and it doesn't look good nor reflective of good care. LVN B also stated it is a dignity issue for residents. During an interview and observation on 06/16/22 at 9:27 AM with LVN C, of the condition of the enteral feeding pumps and pole of resident #7, LVN C stated, everyone was responsible for keeping peg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 6 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tube poles and pumps clean, saying if you see it you should clean it. LVN C stated regarding dirty feeding pumps and poles, there is always a risk of cross-contamination and the residents have a right to have their medical equipment clean. During an interview on 06/17/22 at 11:30 AM with the DON, of the condition of the enteral feeding pumps and pole of four residents, the DON stated anyone can clean the poles and the pumps and tubing nurses need to clean those. She stated there was no schedule for cleaning poles and pumps however, she expects poles and pumps to be cleaned as soon as it is noticed they are dirty. The DON stated the adverse effect on residents could be infection control, environmental, cleanliness, and dignity issues. A Review of Resident #5's Face sheet dated 06/16/2022 revealed he was a [AGE] year-old male that was admitted on [DATE] with a diagnosis of Malignant Neoplasm of Unspecified part of the Unspecified Bronchus or Lung (Cancerous Tumor, Acute Embolism and thrombosis of Unspecified Deep Veins of Lower Extremity Bilateral (Blood Clot). Review of Resident #5 MDS dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment. A review of Resident #5's Care plan dated 6/5/22 revealed the resident has behaviors of throwing items at staff and yelling obscenities, impaired mobility, non-compliance with care and therapy, difficulty adjusting to new environment. In an interview with Resident #5 on 06/16/2022 at 12:32 PM revealed that he could not get up out of bed without assistance from staff. He stated that the facility had not cleaned his room today and leaves the room dirty often. Interview on 06/16/2022 at 12:40 p.m., LVN C said housekeeping had been on the 500 hall a little before noon spraying the handrails, cleaning rooms, floors, and door handles. LVN C said she saw housekeeping removing trash and soil linen but did not see them cleaning the floors. In an interview with CNA T on 06/16/22 at 3:00 PM, revealed that the resident #5 was throwing food earlier, and that this was common behaviors for Resident #5, so it was possible that the facility cleaned the room but during lunch he became angry and three through items on the floor. Interview on 06/16/2022 at 1:00 PM, the Housekeeping Director revealed that she was assigned to this building 2 weeks ago and that a housekeeper was assigned to go every day to clean the resident rooms, floors, bathrooms, and mats. The Housekeeping Director said it was important to keep the rooms clean not only for appearance but for infection control. The Housekeeping Director said that she saw the housekeeping staff cleaning that room. The Housekeeping Director said the that the staff that cleaned Resident #5's room had left for the day, and that she has cleaned the room herself and will conduct an in-service with her staff. She reviewed the room chore task for residents and importance of cleaning and disinfecting. She stated that the facility staff were tenured, and the facility do not need a checklist as the facility know the expectations. She provided an Inservice on 06/17/202 at 9: 00 AM. She stated that it was her expectation for housekeeping staff to maintain a clean and sanitary environment for residents, to prevent self-determination and be free of infections and bacteria. A review of the facility housekeeping list revealed that staff enter the rooms, disinfect bathrooms, clean and dust blinds, floors, toilets, high touch areas, bed rails, remotes control to bed and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 7 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0584 television , call lights. Level of Harm - Minimal harm or potential for actual harm Interview with Director of Maintenance, revealed he has worked at facility for almost a year. He stated he is was responsible for all the cosmetic issues and appearance/functionality of resident's rooms/furniture. He stated he gets most of his requests for these issues through feedback from residents, nursing and other staff. Director of Maintenance stated these types of issues affect residents by not providing them a happy, safe homelike environment. Residents Affected - Few Record review of the Job Description for Housekeeper/Floor Care Technician revealed in part: .Heavy housekeepers/floor care technicians are generally responsible for the overall floor maintenance of hard surfaces and carpet (dusting and wet mopping, stripping, waxing, buffing, shampooing . Review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated August 2011, revealed Policy Interpretation and Implementation 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: a. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue or the vascular system are considered critical items and must be sterile. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 8 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received and the facility provided food prepared by methods that conserved nutritive value, flavor, and appearance; food and drink that is palatable, attractive and at a safe and appetizing temperature. Residents Affected - Some 1.Facility staff failed to offer Resident #1 his meal tray on 06/15/2022. 2.Facility staff failed to provide Resident #2 with her choice of dinner her selection on dining meal ticket. 3.Facility staff failed to provide Resident #4 with food that was palatable despite requests to change the food. This deficient practice could affect residents that are dependent on staff for activities, cognitive stimulation, social interaction, and right to choose, therefore affecting their self-determination with choices. And place them at risk for their rights to be violated. Findings include: Review of Resident #1's face sheet dated 06/14/22 revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses unspecified injury at C3 Level of Cervical Spinal Cord, Subsequent encounter (spinal cord injury causing paralysis) and Depression (mood). Review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 13 which indicated that the resident's cognitive abilities are intact. Review of physician orders for Resident #1's Care Plan dated 05/28/22 revealed that the resident has had weight loss due to changes in his appetite. Resident #1's at risk for pressure ulcers and infection. Interventions listed state that resident should be served diet as ordered, record intake as it was important for him to maintain adequate nutrition. The interventions implemented were to offer health shakes or equivalent two times a day and bedtime snacks. Resident #4's dependent on staff for activities, cognitive stimulation, social interaction related to physical limitations. Interview with Resident #1 on 06/14/22 at 9:30 AM, revealed that Resident #1 that he does not get to choose his meals. He stated that meal tickets are placed on the trays delivered to his room, however, he does not receive his preference of meals selected. He stated that currently he has to purchasing purchase his own food, due to the poor quality of taste and choices. He has verbalized his concerns to the administration and Dietary manager, and they provided him a private room and refrigerator as a solution. He stated that the Dietary Manager met with him after admissions and received a list of food items that he prefers, such as, chef salad, tacos, and chicken. Interview with Resident #1 on 06/15/22 at 11:30 AM revealed that he did not receive any meat on his dinner tray. He stated that the had not received a lunch tray today. He stated that the staff asked Resident #1 what are we having for lunch, and he stated that he would have some crackers. He stated that she did not have a meal tray with her when she entered the room, so he asked for his food. He stated that he did not see what was on his lunch tray today, nor had he seen his meal ticket, because CNA R did not bring the tray in the room. He stated that he did not asked aide about his tray. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 9 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that depending on who was working, they would offer the tray or ask what he wanted from his refrigerator. Resident #1 stated that he refused lunch, dinner and most meals, as the food was not properly prepared, with taste, texture, and smell. In an interview with CNA R, on 06/15/22 at 11:40 AM revealed that she was the aide passing meal trays for Resident #1 today. She stated that she did not offer Resident #1 todays meal tray, because he would not have wanted the choice of food that was served. She stated that he was a very picky eater and most of the time when she offered the meal he would state that he did not want the food. She stated that she did not take the tray in the room. She stated that she did not offer him the tray, by not taking it into the room. She stated that she left Resident #1s tray on the food cart located in the hall. She stated that she was aware that she should have offered him the tray, then when he refused seek alternate meal, and notify the charge nurse to document and communicate to ADON. The aide, nurse, and dietary managers are responsible for assuring that the resident was offered shakes. The nursing station has extra shakes/supplements and snacks available for residents. In an observation on 06/15/2022 at 11:45 AM revealed that Resident #1's tray was observed on the second shelf of 5 at the back. The tray was stored on the cart with other resident trays that had been eaten therefore exposing his tray to other Resident's causing cross contamination. The tray could no longer be offered. The meal tray was observed with a side salad, lettuce, cheese, and tomatoes, black-eyed peas and green beans, mandarin oranges, and milk. The meal ticket lying on the tray stated indicated that resident lunch meal on 06/15/22 Large Portion Xtra Ham Turkey on salad. CNA R was observed pulling Resident #1's food cart from the back of the food cart after removing used resident's trays, therefore unable to offer the tray due to exposure to cross Contamination. A small carton of milk was observed on the tray, however there were no supplements. Review of Resident #2's face sheet dated 06/16/22 revealed an admission date of 06/06/2022 with diagnoses disorder of the Kidney and history Chemotherapy. Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated that the resident's cognitive abilities are intact. Review of Resident #2's Care Plan dated 06/07/22 revealed that the resident has an indwelling and Suprapubic Catheter (a drainage tube is inserted into the bladder via the urethra and is either left in place (indwelling catheter) or removed after the bladder is emptied (intermittent catheter). 2. Suprapubic catheterization: a drainage tube is inserted into the bladder through a small cut in the abdominal wall.) due to a terminal Cancer Diagnosis. Resident #2's at risk for pressure ulcers and infection due to ADL Self-Care Performance Deficit. Interventions listed state indicated that resident should be served diet as ordered, provide supplements as ordered, and record intake as it's important for her to maintain adequate nutrition. The interventions implemented were to offer health shakes or equivalent two times a day and bedtime snacks. Resident #1's dependent on staff for activities, cognitive stimulation, social interaction related to physical limitations. Interview with Resident #2 on 06/14/22 at 12:30 PM revealed that she did not receive the dinner ordered on 06/13/22. She stated that on 06/13/22 when she was served her meal at dinner time in her room, she received a sandwich with turkey no cheese, lettuce, tomatoes, dressing and macaroni salad that was dry and not as described on the menu. She stated that she did not eat the food. Resident #2 did not ask anyone for a meal replacement or substitute, as she stated this happens very often, and nothing changes. Resident #2 stated that she refused meal due to it not being what she asked for and this occurs often. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 10 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0804 Level of Harm - Minimal harm or potential for actual harm An observation and Record review of Resident #2's dinner meal from 06/13/22 at 12:00PM revealed white bread with turkey lunch meat, tea, and macaroni with consistency of scrambled eggs. A review Resident #2's meal ticket revealed that she was served Turkey Sandwich with lettuce and tomato plate, 1 packet of mayonnaise, ½ cup of broccoli salad, ½ cup of creamy dill macaroni salad, and chocolate cake with peanut butter frosting 1 square, milk 8oz, and tea of choice, 6 oz. Residents Affected - Some A review of Resident #4's face sheet dated 06/16/2022 revealed that he was a [AGE] year-old male that was admitted on [DATE] with a diagnosis of Atherosclerotic heart disease of Native Coronary Artery with unstable Angina Pectoris (artery disease related to blood flow deficiencies.) A review of Resident #4's MDS revealed a BIMS score of 12 indicating the resident's cognitive abilities are intact. Review of Resident #4's Care Plan dated 03/29/22 revealed that the Resident #4 was at risk of weight fluctuation as he has snacks in his room due to changes in appetite. Resident #4's at risk for pressure ulcers and infection due to ADL self-care deficit due to limited mobility. Resident #4's interventions states stated that he's dependent on staff for activities, cognitive stimulation, social interaction related to physical limitations. In an interview with Resident #4 on 06/14/2022 at 1:00 PM revealed that he does not like the food at the facility as it does not taste or smell like food. He stated that he has communicated to Resident Council and leadership his concerns with the food, and there have been no changes. He stated that his family member brings him food and snacks to eat to prevent weight loss. He stated that he's very frustrated with the dining services and food provided to the residents as there are very limited choices at mealtime and the variety for alternates. Resident #4 stated that he refused lunch, because the food smells bad and looks like slop In an interview with Resident #4's family member on revealed that her sibling Resident #4 does not like the food at the facility and he's capable of communicating his dislikes to facility staff, yet there have been no changes. RS stated that she brings her brother Resident #4 snacks and food to eat as he will refuse to eat the food that could lead to weight loss. An observation on 06/14/22 at 1:00 PM Resident #4 was observed in his room with his family visiting eating fried chicken, biscuit and mask potatoes that was purchased from Kentucky Fried Chicken. A local fast-food establishment In an interview with the DM on 06/14/2022 at 1:30 PM revealed that she relies relied on the meal tracker to select each resident's diet selection based on the menu. She stated that they do not have a shortage of food at the facility, and that she could not understand why Resident #1 did not receive a salad on 6/15/22 as requested. She stated as for Resident #2 she requested a turkey sandwich and that's what was provided. She stated that she does not know why the resident did not get the additional items of broccoli salad, milk, lettuce, tomatoes, mayonnaise, and chocolate cake. Dietary manager stated that she has supplement shakes in the kitchen and they are supplied at the nursing station. It is the health care staff's responsibility to offer the shakes. She stated that she meets with residents upon admission to gain knowledge of their meal preferences. She stated that she was not aware that many of the residents were not eating their food. She stated that the residents can chose their meals based on what is offered for the today. The facility does not have a select meal program, the facility offers a main choice and an alternate. She stated that when a resident does not like the selection nursing staff are expected to come to the kitchen and request an alternate choice. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 11 of 12 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 675744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that when the facility menu has changed, she does not visit the resident to communicate in advance. The dietary manager stated that she posts the menu's outside of the main dining hall in advance to allow the residents the opportunity to request a grill cheese sandwich or alternate listed on the menus. During a resident council meeting with resident #4 verbalized that the food was not good and he does not believe that they will change the problem. In an observation of lunch on 6/15/22 beginning at 12:00 PM on the 400 hall, 500 hall and 600 halls, approximately over 60% of the plates were refused by the residents without tasting the food. Menu black-eyed peas, green beans, carrots, mandarins and tea. In an interview with CNA T on 06/17/2022 at 9:13 AM revealed that she has witnessed Resident #1 and #2 refuse meals due to the presentation and smell. She stated that she will offer the food trays first and allow the residents to choose to eat or request something else. She stated that she would not eat the food served at the facility nor would she purchase for her family, as it did not look or smell edible. She will document in point of contact fore aides if a resident receives a shake. In an interview with DON on 06/17/22 at 10: 00 AM the DON revealed that communication with the dietary staff about the choices of food available to the residents have been ongoing. She stated that often the reports to the Dietary staff by nursing are met with resistance and delays to the residents. She stated that the residents are were complaining, and this has been addressed int eh in the team meetings on a weekly basis, with little to know change. In an interview with the Registered Dietician on 06/17/22 a 10:00 am revealed that she was responsible for updated the meal select system notifying the kitchen staff to provide supplements to residents. In an interview with Administrator on 06/17/22 at 11:00 AM revealed that it was her expectation for the dietary staff to provide a meal of choice for the residents that's consistent with the residents' desires and presents edible with taste to maintain nutrition. Administrator stated that she has eaten the food at the facility and does not have any complaints. A review of facility policy on Resident Rights revealed that all employees shall treat all residents with respect and dignity, self-determination through choices, communication with and access to people and services at the facility, exercise his or her right as a resident at the facility, be informed about rights, voice grievances and be expected to receive response. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 12 of 12