Inspection·June 8, 2023

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete misplaced about a month ago. He said the facility made several attempts to contact the resident's RP requesting she sign an admission agreement. He said the RP did not answer her phone a lot of the times. He said the RP was refusing to sign the agreement because the RP was wanting to move the resident to another facility. He said an admission agreement had to be signed within 24 hours of admission. He said this timeframe and requirement was not in any policy. He said the business office oversees the admission agreements to ensure they are signed. Event ID: Facility ID: 676006 If continuation sheet Page 2 of 8 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 676006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richmond Health Care Center 705 Jackson St Richmond, TX 77469 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #48) of 6 residents reviewed for baseline care plans. -The facility failed to complete a baseline care plan within the required 48-hour timeframe for Resident #48. This failure could place residents at risk for not receiving necessary care and services or not having important care needs identified. Findings Included: Record review of Resident #48's face sheet, dated 06/08/2023, revealed an [AGE] year-old female with an initial admit date of 02/09/2023. Diagnoses included traumatic subdural hemorrhage (bleeding under the membrane covering the brain) with loss of consciousness, unspecified fracture of T11-T12 vertebra (spinal fracture), unspecified fracture of first lumbar vertebra (spinal fracture), and dementia (group of symptoms affecting memory). Record review of Resident #48's MDS, dated [DATE], revealed a BIMS score of 7 out of 15 indicating a severe cognitive impairment . Functional status revealed the resident required one-person physical assist with bed mobility, transfer, dressing, toilet use, and personal hygiene. Record review of Resident #48's baseline care plan, dated 02/09/23, revealed Sections I (general information and initial goals), II (safety and risk), VI (baseline care plan summary), and VII (RN review) were not completed until 02/13/2023 and Section III (health conditions) was not completed until 02/14/23. During an interview on 06/08/2023 at 2:52 p.m., the DON said the timeframe to have the baseline care plan completed was within 72 hours after the resident was admitted to the facility. She said the resident's baseline care plan was not completed timely. She said there was no reason for it being completed late. She said the risk posed to a resident if it were not completed within the required timeframe was the aides and nurses would not know the resident's level of care. She said if staff did not know their level of care, they could cause harm to the resident. Record review of the facility's Care Plans - Baseline policy revised December 2016, read in part . Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 3 of 8 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 676006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richmond Health Care Center 705 Jackson St Richmond, TX 77469 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 1 (Resident #6) of 7 residents reviewed for medication administration. -1) MA L dispensed medications for Resident #6 but was following the MAR of Resident #44. -2) Surveyor intervention was necessary to prevent the possibility of Resident #6 receiving incorrect medications. These failures could place residents at risk for receiving the wrong medications and the possible complications from those medications. Findings Include: Record review of the admission Record for Resident #6 (printed on 06/08/2023) revealed Resident #6 was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included, but were not limited to, seizures, dementia (decreased ability to think), chronic obstructive pulmonary disease (difficulty breathing), and congestive heart failure (weak heart). Record review of the Quarterly MDS dated [DATE] revealed a score of 5 out of 15, indicating severe cognitive impairment. Record review of Resident #6's Care Plan not dated read in part . re-admission date 06/07/2023. Focus: resident had a seizure disorder. Intervention: administer medications as ordered Observation and interview on 06/08/2023 at 7:57 a.m. revealed MA L standing in the doorway of Resident #6's room. He said he was going to administer medications for Resident #6. The identifier sign on the wall next to the doorway reflected the name of Resident #6. Resident #6 was observed to be lying on his bed. Observation revealed the laptop computer on the medication cart facing MA L. The resident name on the displayed MAR was that of Resident #44. MA L opened the third drawer of the medication cart and retrieved a stack of medications cards. He began dispensing medications from the cards. Observation revealed the cards had Resident #6' name, but the MAR was still that of Resident #44. MA L dispensed one tablet of Amlodipine 10 mg (for high blood pressure), one tablet of aspirin 81 mg, one tablet of Keppra 500 mg (for seizures), one tablet of Sevelamer Carbonate 800 mg (to treat kidney disease). MA L said Resident #6 was to receive 100 mg of Metoprolol Tartrate (for high blood pressure), but he only had 25 mg tablets. He dispensed four 25 mg tablets. Further observation revealed MA L place the medication cards back into the cart. The surveyor noted the location of where MA L placed the cards: third drawer, second from the front. MA L then closed out the screen on the laptop. MA L placed the dispensed medications into a plastic sleeve to be crushed. At that time, the surveyor asked MA L to pause. The surveyor asked MA L to pull up the MAR he was using on the screen. MA L pulled up the MAR for Resident #44. MA L confirmed that was the screen he used. The surveyor informed MA L that the name on the MAR was that of Resident #44. MA L acknowledged. MA L said he had not worked the previous two days, and that the residents 'changed names.' He said he pulled medications for the wrong resident, and he would destroy them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 4 of 8 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 676006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richmond Health Care Center 705 Jackson St Richmond, TX 77469 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 06/08/2023 at 10:28 a.m. revealed the Administrator asked the surveyor to meet with him, the Regional Nurse, the DON, and MA L. in the Administrator's office. MA L said he was dispensing the medications for Resident #44 because he was going to dialysis. He acknowledged Resident #44's MAR was on the screen. MA L acknowledged he was showing the surveyor each medication card as he dispensed the medications, and that the surveyor was writing notes. MA L said he did not recall whose name was on the medication cards he was dispensing from. He said the medications he was dispensing were for Resident #44, not Resident #6. At that time, the surveyor asked MA L to bring his medication cart. MA L brought the cart to the doorway of the Administrator's office. Prior to MA L opening the cart, this Surveyor presented his notes from the medication pass observation. The note reflected the medication cards used to dispense the medications were in the third drawer, second from the front. The surveyor added that the location was on the left side of the drawer. The DON accompanied MA L and this Surveyor to the cart. MA L opened the third drawer of the cart. This Surveyor asked MA L to retrieve the medication cards that were in the third drawer, left side, second from the front. MA L retrieved the cards and placed them on the left side of the top of the cart. MA L and the DON acknowledged they were those of Resident #6. MA L then retrieved a stack of medication cards from the right side of the drawer. They were the medication cards for Resident #44. He placed them on top of the cart. This Surveyor asked MA L to demonstrate which resident's medication cards contained Amlodipine. MA L sorted through the cards for Resident #44 but did not locate any Amlodipine. MA L then located Amlodipine 10 mg in Resident #6' cards. Both residents had Keppra and Sevelamer Carbonate in their medication cards. MA L presented a medication card for Resident #44 that contained Metoprolol Tartrate 100 mg tablets. This Surveyor presented the note from the medication pass observation that reflected MA L had dispensed four 25 mg tablets of Metoprolol Tartrate from Resident #6' card. MA L sorted through Resident #6' medication cards and presented one that contained Metoprolol Tartrate 25 mg. Interview on 06/09/2023 at 11:44 a.m. with the DON, she said the proper procedure was for the nurse or MA to check vital signs, then apply the '6 Rights.' She said, Having the right MAR in front of you is key. She acknowledged the medications were likely those of Resident #6. She said the '6 Rights' were not done. Record review of a facility policy Titled: Six Rights of Medication Administration dated September 2013 read in part . Right Resident - Identify resident to assure you are giving the medication to the resident who is supposed to receive the medication and using procedure required by the facility, such as a photo on the MAR, asking the resident his/her name, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 5 of 8 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 676006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richmond Health Care Center 705 Jackson St Richmond, TX 77469 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen, reviewed for sanitation in that: 1) The facility failed to ensure the stove's vent hood was free from dust build-up. 2) The facility failed to ensure the ice machine's vent cover was free from grease and dust build-up. These failures could affect all residents who receive meals from the kitchen and place them at risk for foodborne illness. Findings Include: Observation on 06/06/2023 at 8:40 a.m. accompanied by the DM during a walk-through inspection of the kitchen revealed the following: -Dust build-up on the stove vent hood. -Dust and grease build-up on the ice machine's vent cover located above the ice bin. Observation on 06/06/2023 at 8:45 a.m. of the stove's cleaning sticker located on the hood revealed it was last serviced by an outside company on April 12, 2023, and the next service due date was 07/2023. During an interview on 06/06/2023 at 8:45 a.m., the DM acknowledged the dust build-up on the stove's vent hood. She also acknowledged the dust and grease build-up on the vent cover located on the ice machine. She said the stove's vent hood was cleaned in between serviced dates. She said additional cleanings of the vent hood were based on usage. She said the last time she cleaned the vent cover on the ice machine was about a week ago. She said she checked the stove's vent hood every couple of weeks. She said the stove's vent hood did not require additional cleanings in between the serviced date very often. She said when a cleaning was required, she worked together with the Maintenance Director to ensure it got cleaned. During an interview on 06/08/2023 at 7:10 a.m. the Maintenance Director said he had been working at the facility for a year. He said he worked together with the DM to clean the stove's vent hood if additional cleanings were needed, but the DM handled the in between cleanings on her own. He said he could not recall if the DM requested that he clean the stove's vent hood prior to the survey. He said the computer program that was used to track maintenance tasks included the vent hood. He said the potential risk of not keeping the vent hood free from dust build-up was food contamination and the potential for becoming a fire hazard. During an interview on 06/08/2023 at 7:47 a.m., the DM said she had been working at the facility for about a year. She said the potential risk of not keeping the stove vent hood free from dust build-up was that it could be a potential fire hazard. She said dust and grease accumulates quickly on the vent cover located on the ice machine. She said she monitored it and cleaned it once a week. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 6 of 8 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 676006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richmond Health Care Center 705 Jackson St Richmond, TX 77469 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 0812 Level of Harm - Minimal harm or potential for actual harm said the potential risk of not keeping the vent cover free from dust and grease build-up was dirty ice which could exposed residents to bacterial infection. Record review of the dietary Food & Nutrition: Ice Machine - Cleaning & Sanitation Log revealed the ice machine was cleaned on 05/29/2023. Residents Affected - Few Record review of the dietary's Weekly Cleaning Schedule revealed the ice machine was cleaned on 05/29/2023 and the vent hood and filters on 06/01/2023. Record review of the facility's policy titled: Hoods and Filters policy revised June 1, 2019, read in part . The facility will maintain hoods and filters in a clean and sanitary manner to minimize the risk of food hazards. Hoods and filters will be cleaned every 6 months or as needed . Record review of the facility's policy titled: Ice Machines dated October 1, 2018, read in part . The facility will maintain the ice machine . in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. Procedure: 5. Clean the exterior with detergent solution and rinse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 7 of 8 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 676006 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richmond Health Care Center 705 Jackson St Richmond, TX 77469 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 1 of 1 facility reviewed for pest control. Residents Affected - Few -The facility failed to ensure it was free from ants. This failure placed residents at risk of a decreased quality of life. Findings included: Observation on 06/07/2023 at 10:13 a.m. of the entrance door to the kitchen and coffee station located in the dining room revealed the following: -Small black bugs ranging from 1 to 3 mm were crawling around the doorframe of the entrance door to the kitchen. -Small black bugs ranging from 1 to 3 mm were crawling on the plastic food tray where two large stainless steel coffee dispensers were sitting on top. During an interview on 06/07/2023 at 10:20 a.m., the Maintenance Director acknowledged that there were small black bugs crawling around the doorframe and coffee station. During an interview on 06/08/2023 at 7:10 a.m., the Maintenance Director said the facility had a pest control company that came once a month or as needed. He said the small black bugs were sugar ants. He said he was not aware that there were sugar ants prior to the survey. He said he believed dietary was responsible for maintaining the coffee station. He said the potential risk posed to residents when there were pests in the building was infections. During an interview on 06/08/2023 at 7:47 a.m., the DM said dietary was responsible for maintaining the coffee station. She said she never noticed sugar ants around the station. She said dietary staff cleaned the station in the morning and throughout the day. She said she did not know where the ants came from. Record review of the facility's pest control receipts revealed their pest control company last treated the facility on 05/06/2023. Record review of the facility policy titled: Pest Control revised May 2008, read in part . Our facility will maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 8 of 8