Inspection·March 29, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said she had been in-serviced a couple of months ago and was aware that she was supposed to wear PPE when transferring Resident #1 to her bed. She said she was in a rush to try to assist ADON A and forgot to put on her gown and gloves. During an interview on 3/29/2025 at ADON A said personal protective equipment should be worn when transferring Resident #1. ADON A said wearing PPE protected the resident. ADON A said she had been educated on EBP and PPE and should have donned (to put on and use PPE properly to achieve the intended protection and minimize the risk of exposure) her gloves and gown. ADON A said the infection control training was a couple of weeks ago and included EBP. She said the risk of not wearing PPE was infection. Record review of Resident #2's undated face sheet indicated the resident was a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of cerebral infarction (blood flow to the brain is blocked, leading to brain tissue damage), Hemiplegia (paralysis or weakness on one side of the body), and Type 2 Diabetes( long-term condition in which the body has trouble controlling blood sugar). Record review of Resident #2's Quarterly MDS assessment, dated 12/18/2024, revealed a BIMS summary score of 13, indicating cognitively intact. Record review of Resident #2's care plan initiated on 9/05/2024, indicated Resident #2 was at risk for an ADL Self Care Performance Deficit related to decline in health. The interventions included providing total assistance of 1-2 staff participation to use toilet/incontinent care. Observation and Interview on 03/29/25 at 11:35 AM Resident #2 said the staff provided incontinent care routinely and as needed. She denied skin break down and said the CNA was about to provide incontinent care because she had a bowel movement. Observation of incontinent care on 03/29/25 at 11:45 AM, CNA J was observed performing incontinent care. CNA J introduced herself and explained the incontinent care procedure. CNA J did not wash her hands prior to initiating incontinent care. She double gloved and cleaned Resident #2's abdominal folds times one wipe and proceeded to clean labia per protocol. CNA J removed her 1st set of gloves, as she was doubled gloved. CNA J turned the resident to her left side and cleaned the stool from the resident's buttocks in an upward motion with several wipes using the same gloves. CNA J used the same soiled gloves that held the dirty wipes to reenter the multi-wipe package. Stool was noted on outside of multi-wipe package. She removed and discarded the soiled brief. She opened Resident #2's barrier cream and applied the cream to the resident's buttocks. She applied a new brief and removed her gloves. She discarded the trash and used hand sanitizer once completed. During an interview on 3/29/2025 at 11:51 AM, CNA J said she double gloved because Resident #2's bedside table was cluttered and there was no place to setup her supplies. She said there was no hand sanitizer available in the room and would have to go in the hallway to sanitize her hands. She said she did not wash her hands, but she did use sanitizer prior to donning gloves and after completion of incontinent care. CNA J said the risk of using the same gloves and double gloving was spreading infection and cross contamination. Record review of Resident #3's undated face sheet indicated the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of acute pyelonephritis (Kidney infection, an illness in one or both kidneys), paraplegia (complete or partial paralysis of the lower half of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 2 of 4 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 03/29/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the body), and Neuromuscular Dysfunction of Bladder (condition that affects the muscles and nerves that controls the bladder). Record review of Resident #3's Quarterly MDS assessment, dated 03/10/2025, revealed a BIMS summary score of 15, indicating cognitively intact. Section H indicated Resident #3 had an Indwelling catheter (including suprapubic catheter- a medical device that helps drain urine from your bladder; and, nephrostomy tube - a tube that lets urine drain from the kidney through an opening in the skin on the back) Record review of Resident #3's care plan initiated on 9/05/2024, indicated Resident #3 had Indwelling Catheter due to diagnosis of Neurogenic bladder. His interventions included to Observe/record/report to MD for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 03/29/2025 at 12:49 PM of CNA G and LVN D performing incontinent care on Resident #3. Contact isolation signage on Resident #3's door. It was observed both CNA G and LVN D wearing proper PPE while initiating incontinent care on Resident #3. CNA G and LVN D performed hand hygiene, donned clean gloves, and LVN D provided a barrier on bedside table and added supplies. CNA G began cleaning subpubic Cather per policy. Next, she began wiping Resident #3's abdominal folds, groin, and penial area. CNA D used same soiled gloves that held the dirty wipes to reenter the multi-wipe package. CNA G proceeded to clean Resident #3's left and right groin area multiple times. CNA G turned Resident #3 to his left side and wiped his buttocks in an upward motion. CNA G then turned Resident #3 to the right side, wiped his buttocks in an upward motion until no discoloration was noted on the wipes. CNA G doffed gloves, no hand hygiene was performed, and donned clean gloves. CNA G applied a new brief, while LVN D discarded the soiled brief and wipes. CNA G and LVN D doffed gloves, and they washed their hands. During an interview on 3/29/2025 at 1:15 PM, CNA G said that the staff did frequent training and in-services on infection control and incontinent care. She said she did not use hand sanitizer prior to donning new gloves because she did not have any sanitizer to use. She said staff should wash and/or sanitized hands per policy. She said the risk of not washing hands could cause infection to self or other residents. During an interview on 3/29/2025 at 5:04 PM, ADON B (Infection Preventionist) said all staff had been in-serviced on enhanced barrier precautions (EBP). She said she did a training every Wednesday on infection control to include handwashing, incontinent care, and EBP. She said PPE should be worn when providing direct care by wearing gowns and gloves. She said the facility would re-educate staff on wearing PPE with residents on EBP and proper handwashing and incontinent care. She said the last in-service on infection control was 12/12/24 (FTG), 02/29/25 (EBP), and 03/13/25 (Infection control concerns for Resident #1). ADON B said the risk of not following EBP and not sanitizing hands could cause infection and cross-contamination. During an interview on 3/29/2025 at 5:30 PM, the DON said the facility had frequently in-serviced staff on enhanced barrier precautions (EBP) and infection control. The DON said she expected her staff to wear proper PPE when providing care. She said she would implement peri-care checkoffs and return demonstration with the administrative staff for the next 3 months. She said the risk was cross contamination and infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 3 of 4 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 03/29/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 3/29/2025 at 6:49 PM, the Administrator said he expected the nurses and staff to adhere to the enhanced barrier precautions/infection control policy. He said handwashing was infection control was CNA 101. The Administrator said the risk of not following the infection control policy puts the staff and residents at risk for contracting an infection, passing it on to other residents or staff, which can lead to an outbreak. Residents Affected - Some Record review of a policy titled Enhanced Barrier precautions dated April 1, 2024, read in part . Policy: EBP are used in conjunction with standard precautions and expand the use of PPR to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering transferring providing hygiene changing linens, changing briefs or assistance with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care any skin opening requiring a dressing . Record review of a policy titled Handwashing/Hand Hygiene revised on August 2015, read in part, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors &. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675744 If continuation sheet Page 4 of 4