Inspection·February 9, 2024

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/09/24 at 10:10a.m., with Resident#2, she said there was an increase as of January 1st on the Social security allowance from $60 to $75. She said she received an allowance on the 3rd Wednesday of each month. Resident#2 provided a bank statement to Surveyor A to show the payment of $60 received on Wednesday, January 17, 2024. She said she had a neurologist appointment on Wednesday (02/07/24) which she had to cancel. She said when she got to the appointment, she was asked to pay co-pay of $34. She said, If I had paid $34 co-pay out of $60, I would not have enough money to last me until I get the next allowance. In an interview on 02/09/2024 at 11:01 a.m., the Social Worker said Resident#2 had a neurologist follow up appointment on Wednesday (02/07/24) that she had scheduled. She said when Resident #2 went to the neurologist the front office asked for a $34 copay. She said the facility's scheduling coordinator that accompanied Resident#2 called and informed her that the resident had to pay a copay and the resident refused to pay. She said she went and asked the business office if we cover the co-pay the business office said she was not sure. SW said she asked interim Administrator yesterday (02/08/24) if we ever pay copay and he said yes, we can.'' In an interview on 02/09/2024 at 11:24 a.m., the interim Administrator said after Surveyor A brought it to his attention, the BOM reconciled, and a few residents were short paid $15 last month (January). He said it was an honest error on the Business Office Manager's part. Resident #2 got cash in advance, so it was an error in calculation. He said corporate spot checked BOM and the corporate said it was overlooked on her part. In an interview on 02/09/2024 at 12:04 p.m., with the BOM, she said she started working at this facility towards the end of November of last year. She said she was still in training. She said residents funds went directly into the resident trust fund account. When the resident asked for money, she gave $60, and the rest went towards the care cost of the month. She said it was discussed in training, at that beginning of 2024, there was an increase from $60 to $75. She said, I'm finding out now that I have to deduct $75, and the rest will go to care cost depending on patients' liability. She said sometime this week the social worker came to her and asked her how the copay was taken care of. BOM said Resident#2 had Medicare/Medicaid, but the resident went to an appointment which was out of network. She said interim Administrator told her today that the facility could pay with the company card so the resident would not miss appointments. In an interview on 02/09/2024 at 12:34 p.m., the ADON said, the Social Worker was responsible to set up the appointments and facility transportation for the resident to their appointment. She said Resident#2 had a follow up appointment with the neurologist this week but she was not aware that the resident canceled the appointment because of co-pay. She said when setting up the appointment the Social Worker needed to find out if there was a co-pay. In an interview on 02/09/2024 at 1:33 p.m., the interim Administrator said, I was not aware of any resident missing a doctor's appointment because they were short paid $15 last month. When asked who was responsible to ensure the staff were trained regarding this. He said at corporate level, notices were sent to the facilities Administrators about the increase. He said, I don't know if the previous Administrator notified the BOM. That's the previous administrator's question. Record review of the facility's Surety Bond policy (Revised March 2021) read in part: .Policy Statement: Our facility has a current surety bond to assure the security of all residents' personal fund deposited with the facility. Policy Interpretation and Implementation: 2. This facility holds a surety bond to guarantee the protection of residents funds managed by the facility on behalf of its (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 2 of 9 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 02/09/2024 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 0567 Level of Harm - Minimal harm or potential for actual harm residents. 4. The purpose of the surety bond is to guarantee that the facility will pay the resident for losses occurring from any failure by the facility to hold, account for, safeguard, and manage the residents funds (i.e., losses occurring as a result of acts or errors of negligence, incompetence or dishonesty) . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 3 of 9 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 02/09/2024 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 of 2 residents (CR #1) reviewed for discharge requirement, in that: -The facility failed and refused to readmit CR #1 from the hospital where he was transferred for evaluation and treatment. This failure placed residents at risk of not receiving care and services to meet their needs upon discharge. Findings included: Record review of CR#1's Face Sheet (undated) revealed, a [AGE] year-old male who admitted to the facility on [DATE] and discharged to acute care hospital on [DATE] with diagnoses which included: fracture of unspecified part of neck or right femur (type of hip fracture of the thigh bone (femur) just below the ball of the ball-and-socket hip joint), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and cognitive communication deficit (those thought processes that allow humans to function successfully and interact meaningfully with each other). (Date of Discharge 01/17/2024 at 10:30pm to acute care hospital) Record review of CR#1's Discharge MDS assessment dated [DATE] revealed a BIMS score of blank indicating severely impaired cognitively. He required substantial/maximal assistance with bed mobility, dressing, personal hygiene, and toilet use. CR#1 was occasionally incontinent of bladder and always incontinent of bowel. Section A. Entry/discharge reporting coded: 11. Discharge assessment-return anticipated. Record review of CR #1's electronic medical records on 02/09/2024 revealed CR #1 did not have a Baseline Care Plan. Record review of CR #1's nurses notes dated 01/18/2024 at 1:25am written by LVN B revealed read in part: .around 2230 [EMS company] here to transport resident to [hospital name] ER. Alert and oriented, no distress noted . In a telephone interview on 02/09/24 at 9:03 a.m., with CR#1's family member, she said as per family's request CR#1 was sent to the ER around 10:00-10:30pm on 1/18/24. The doctor at the hospital did a CT of the stomach and it showed the CR#1's bowels were full and ordered an enema. By 3:30-4am CR#1 was cleared to go back to the facility to continue rehabilitation services. She said the ER nurse in charge said policy dictated that he was an outpatient and was required to go back to the facility. EMS workers loaded CR#1 along with her and went back to the facility. Upon arrival at the facility, LVN B said that policy was that if he was out past midnight that Medicare would not pay. LVN B said that the hospital had to call to readmit him and that he forfeited his bed at that facility. The family member said she asked what she needed to do with CR#1 and LVN B did not care. The EMS workers said if the facility denied entry than they had to transport CR#1 back to the hospital. The nurse denied him at the facility and so without any choice EMS loaded CR#1 and her back up and went back to the hospital. The hospital staff were adamant that the facility could not deny him because he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 4 of 9 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 02/09/2024 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 0626 Level of Harm - Minimal harm or potential for actual harm considered outpatient. They proceeded to call several administrators at the facility and by 6am the EMS had to go, so CR#1 was put in an ER bed and they waited. CR#1 was completely exhausted and was in a state of confusion and had anxiety about being transported back and forth. Family member said, CR#1 is 89 and has dementia. This was such a roller coaster for him. She said she ended up taking him home for a few hours while the new facility worked with insurance to expedite his transfer. Residents Affected - Few In an interview on 02/09/24 at 10:46a.m., with the interim Administrator, he said CR#1 was sent to the hospital and the hospital sent the resident back around 2am without calling a report to the facility and without an authorization. He said CR#1 had insurance that required an authorization after midnight. He said the facility needed authorization from his insurance company, without an authorization the resident would be private pay. In an interview on 02/09/24 at 12:34p.m., with the ADON, she said she received a call from LVN B that CR#1 was sent to the hospital as per family's request. The previous administrator said the resident was not allowed to come back to the facility after midnight, it had something to do with the insurance. CR#1 was sent to the facility from the hospital without calling a report. The ADON said it was late at night, but she tried calling the previous Administrator regarding denied entry. The previous Administrator did not answer. She said she called the Marketing Representative and she said that the resident was allowed entry to the facility regardless the type of insurance the resident had. The ADON said she called LVN B to allow CR#1 entry to the facility. LVN B said that EMS ended up taking the resident back to the hospital. The ADON said she called the hospital and notified them that the resident could return to the facility and that the facility was not denying entry. She said the hospital staff said that the resident was back at the ER, and they had to restart the whole process. The ADON said, either way we got to take the resident back. I don't know why the previous Administrator did not allow entry. In a telephone interview on 02/09/24 at 1:09a.m., with LVN B, she said as per the family's request CR#1 was transferred to the hospital. LVN B said the facility's policy was anytime a resident was sent to the hospital the nurse needed to notify the Administrator. She said she called the previous Administrator, and the previous Administrator asked her for the type of insurance that CR#1had. She said she looked at the resident's insurance from the EMR and gave the information to the Administrator. The previous Administrator said that CR#1 would not be able to readmit after midnight due to the type of insurance he had. LVN B said CR #1 showed up at the facility's door with the EMS the same night. She said she told the family member that the resident was not allowed re-entry to the facility as per the administrator. She said that EMS ended up taking CR#1 back to the hospital. In an interview on 2/9/24 at 3:16p.m., with the interim Administrator and the Regional Nurse, the interim Administrator said per (managed care insurance) policy, they can't accept the resident without authorization unless they are private pay. He said managed care insurance that CR #1 had, ran from midnight to midnight. If the resident was to return after midnight an authorization was required for reentry, or the facility would not get paid. He said the resident was not allowed entry because the facility had to call the insurance. It was 1:00am in the morning and the facility had to wait for the insurance company to open in the morning to obtain authorization. Record review of facility's Transfer or Discharge Notice dated (Revised March 2021) read in part: .Policy Statement: Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty (30) days prior to a transfer or discharge. Policy Interpretation and Implementation 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 5 of 9 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 02/09/2024 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Transfer and discharge includes movement of, a resident from a certified bed in the facility to a noncertified bed in another part of the facility, or to a non-certified bed outside the facility. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Specifically: a. transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and b. discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. 2.Residents are permitted to stay in the facility and not be transferred or discharged unless: a. the transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. c. the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. (1) Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. 2) For a resident who becomes eligible for Medicaid after admission to a facility, the facility will only charge a resident allowable charges under Medicaid. d. the facility ceases to operate . Event ID: Facility ID: 676006 If continuation sheet Page 6 of 9 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 02/09/2024 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 interviews and records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (CR#1) out of 3 residents reviewed for base-line care plans. -The facility failed to ensure CR#1 had a baseline care plan developed within 48-hours after admission with goals and interventions. The failure could place newly admitted residents at risks of not receiving the care and continuity of services. Findings included: Record review of CR#1's Face Sheet (undated) revealed, an [AGE] year-old male who admitted to the facility on [DATE] and discharged to acute care hospital on [DATE] with diagnoses which included: fracture of unspecified part of neck or right femur (type of hip fracture of the thigh bone (femur) just below the ball of the ball-and-socket hip joint), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and cognitive communication deficit (those thought processes that allow humans to function successfully and interact meaningfully with each other). Record review of CR#1's Discharge MDS assessment dated [DATE] revealed a BIMS score of blank indicating severely impaired cognitively. He required substantial/maximal assistance with bed mobility, dressing, personal hygiene, and toilet use. CR#1 was occasionally incontinent of bladder and always incontinent of bowel. Record review of CR #1's electronic medical records on 02/09/2024 revealed CR #1 did not have a baseline care plan. In an interview on 02/09/2024 at 12:30 p.m., with the Regional Nurse and the interim Administrator, Regional Nurse said she looked in CR#1's EMR and could not locate a base-line care plan for CR#1. Regional Nurse said the base line care plan was a collaboration of IDT/ and nurse leadership. Regional Nurse said nurses needed to follow the plan of care. In an interview on 02/09/2024 at 12:34 p.m., the ADON said baseline care plans were supposed to be developed within 48-hours after admission by the nurses on the floor/management (DON, ADON) and different departments (dietary, activities). She said she and the DON were responsible for checking for completion. She said she checked UDA every day if not every other day. She said UDA were (assessments that patient was scheduled). She said the importance of the baseline care plan was to provide nursing staff with information and interventions about residents so the staff could provide appropriate care and services. The ADON said CR#1's baseline care plan was missed. 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 7 of 9 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 02/09/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 (Resident #2) of 2 residents reviewed for respiratory care. Residents Affected - Few -Resident #2's Nebulizer mask was not labeled/bagged while not in use on 02/09/2024. This failure could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Record review of Resident#2's Face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: chronic systolic congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypertension (a condition in which the force of the blood against the artery walls is too high), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident#2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. She was independent with bed mobility, dressing, personal hygiene, and toilet use. Resident#2 was continent of bladder and bowel. Record review of Resident#2's Care Plan initiated 08/28/2023 and updated on 01/19/2024 revealed the following: Focus: Resident has COVID-19 infection related to Multiple Co-morbidities. Goal: Resident will have minimal complications associated with the COVID-19 infection through next review date. Interventions: Assist resident with ADL's in room as indicated. Assist resident with application of a face mask when exiting their room. Remind resident to wash hands/perform hand hygiene before and after meals and as needed. Resident will adhere to room restrictions. Resident will don a face mask when staff are in the their room. Record review of Resident #2's physician order dated 08/24/24 revealed an order to administer Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 milliliter inhale orally three times a day for Wheezing at 9:00am, 2:00pm, and 9:00pm. Record review of Resident #2's physician order dated 02/09/24 at 1:14pm by the Regional Nurse for Nebulizer tubing: change nebulizer tubing when visibly soiled or malfunction present every 12 hours as needed AND every night shift every Sun. Observation and interview on 02/09/24 at 10:10 a.m., with Resident#2 revealed her sitting on the side of the bed. Resident's nebulizer mask was sitting on top of the bedside table not labeled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 8 of 9 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 02/09/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few orbagged while not in use. Resident#2 said she received routine breathing treatment several times a day. She said she was not sure how often the nebulizer mask set was changed. She said, I had COVID two weeks ago and had to request the nurse to change the neb mask, so I don't get re-infected. Observation and interview on 02/09/24 at 10:39 a.m., with LVN A revealed Resident #2 was resting on her bed. Resident's nebulizer mask was sitting on top of the bedside table. LVN A said Resident #2's nebulizer mask was not dated and not bagged while not in use. LVN A said nebulizer mask and tubing was supposed to be changed weekly by the nurses. She said it was standard practice to change/label tubing. She said MAR/TAR prompted nurses to change the set. She said the risk of not changing the neb mask was infections. She said she administered the routine breathing treatment this morning but did not check for the label/date and forgot to place the mask back in the bag after use. In an interview on 02/09/24 at 12:34 p.m., with the ADON, she said the nurse that entered the treatment order needed to enter the order to change tubing/neb mask every Sunday. She said there was a place on the MAR or TAR for nurses to sign off after the nurse changed the tubing. The ADON said the nurses should be checking prior to administering the treatment. She said the risk of not changing the nebulizer mask was infections. Record review of facility's Department (Respiratory Therapy)-Prevention of Infection policy (Revised November 2011) read in part: .Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents, and staff. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. 9. Discard the administration set-up every seven (7) days . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676006 If continuation sheet Page 9 of 9