Inspection·September 4, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record Review of Resident #2's history and physical dated 1/5/24 reflected a [AGE] year-old female with the following diagnosis Diabetes, Hypertension. Record Review of Resident #2's MDS assessment section C, cognitive patterns, dated 4/23/24 reflected a BIMS score of 15. (BIMS assessment use a point system that range from 0-15. Points ranging from 13 to 15 points suggest cognitive intact). Interview on 9/4/24 at 11:25am Resident #2 stated we have flies and once or twice I have seen those small roaches. Housekeeping comes in and use a Swiffer to mop these floors. Sometimes we cannot eat our food in peace because we are swatting off gnat's flies or whatever. I have told the nurses about it, but it falls on deaf ears. Resident #2 stated she has adjusted to the flies they come, and they go it just depends. Resident #2 stated that her roommate's caregiver has complained to upper management, but nothing seems to happen. Resident #2 stated it is bad when it is hot outside and I just stop asking my family to stop bringing me any kinds of fruits. Resident#2 stated she likes fruits but will avoid them if he causes fruit flies. Resident #2 stated she had boxes around her bed she need help to go through and stated they move things to clean, they just clean around when they do clean. I have noticed some days we don't have our room cleaned because they are short staffed and when you ask them to clean, they have an attitude, so I do not ask. Based on observation on 9/4/24 at 12:00pm Resident #2's side of the room was can goods, chips, crackers, bottled water. Under Resident #2's bed was tissue paper, trash underbed, the bedside table had a water pitcher and a glass of juice. Resident #1 clothing was on stand near the bathroom door. The bathroom trashcan had trash full, the floor in the Resident's #1 and #2 room was sticky. Resident's #1 and #2 room had clutter such as briefs, bed padding and clothing in a space at shelving near the closet not in the drawers. Interview with CNA (refused to give name) on 9/4/24 at 12:30pm stated there was no housekeeper on 300 Hall so that is why a lot of the rooms are dirty. Interview with DON on 9/4/24 at 1:00pm, the DON stated she was not aware of Resident's #1 and Resident #2 room needing cleaning and she would get the CNA to clean the room and let the Administrator know what was going on. The DON stated she was not aware there was not a housekeeper on 300 Hall. The DON stated we have been having issues with housekeeping. Interview with the Administrator on 9/4/24 at 1:30pm, the Administrator stated he was made aware of the issues with residents' rooms not being cleaned daily and will jump on it right away and plan to have a meeting with housekeeping. The Administrator stated we have had several issues in that department, and I plan on working on making some changes moving forward. The Administrator stated the room should have been cleaned much earlier than what it was and it will be going forward as a priority. The Administrator stated that all housekeeping staff have a sign off log that is kept in some rooms for housekeepers to sign off to justify the room had been cleaned. The Administrator stated he was not aware there was not a housekeeper on 300 Hall. On 9/4/24 at 1:45pm, policies were requested from the Administrator covering the expectations for a safe, homelike environment but none could be located per Administrator. Attempted to interview Housekeeping Supervisor on 9/4/24 and was told she was out of the building. Interview with housekeeper on 9/4/24 at 2:00pm on 400 hall, stated she was covering for 2 halls due (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 2 of 3 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 09/04/2024 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 a call in. Housekeeper stated they were short staffed, and she was making her rounds to 300 hall. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 3 of 3