Health inspection·July 27, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sandwich, but received a roll and tartar sauce on her plate. Requested sugar free syrup and received regular syrup. Laundry: Resident shirt returned from laundry torn, marked and with holes. Clothes retuned with strings hanging, need scissors to cut threads. Maintenance - Resident mentioned (several times) that the bathroom sink was too high - it needs to be lowered. Needs air filter changed in room. Further review of the April 2023 minutes revealed Agenda Last meeting follow-up 1. All concerns from the previous meeting were addressed. New Business 2. All current concerns with the departments in the facility. However, there was no indication that the department heads returned the form to the AD, or that it was submitted to the Resident Council President for review with the group. Record review of Resident Council Minutes for 05/16/2023 revealed the following concerns: Administrator Resident waited for her pictures and books to be returned to her room when she moved 6 months ago and has not heard a response on the whereabouts of the items. Nursing - Resident down the hall's television was loud at night. Staff talked on their cellphones will providing patient care. Resident does not want to be weighed right after a meal. Dietary - Resident requested/circled apple juice on menu and served orange juice. Resident was allergic to orange juice. Marked out ice cream and requested fresh fruit. Received fresh fruit and ice cream. Activities - Resident cellphones needed to be silenced during bingo. Laundry: Resident's bra and shirts returned damaged. Clothes retuned with strings hanging, need scissors to cut threads. Maintenance - Needs air filter changed in room. Carpet needed cleaning in halls. Further review of the May 2023 minutes revealed Agenda Last meeting follow-up 1. All concerns from the previous meeting were addressed. New Business 2. All current concerns with the departments in the facility. However, there was no indication that the department heads returned the form to the AD, or that it was submitted to the Resident Council President for review with the group. Record review of Resident Council Minutes for 06/20/2023 revealed the following concerns: Nursing Resident down the hall's television was loud at night. On 06/07/2023 staff cellphone alarm went off during patient care. Staffing short. Activities: Bingo money should be paid out at time of win. Dietary - Resident continued to circle other juices on menu and was served orange juice. Resident was allergic to orange juice. On 06/17/2023 served cold grits and warming plate barely hot. Requested sugar free syrup and received regular syrup. Menu stated beef enchiladas, resident received bean and cheese enchiladas. Resident requested/circled apple juice on menu and served orange juice. Resident was allergic to orange juice. Requested fresh fruit, received canned fruit cocktail. Laundry: Resident new shirts returned from laundry marked with holes. Shirt with lace torn. Clothes retuned with strings hanging, need scissors to cut threads. Further review of the June 2023 minutes revealed Agenda Last meeting follow-up 1. All concerns from the previous meeting were addressed. New Business 2. All current concerns with the departments in the facility. However, there was no indication that the department heads returned the form to the AD, or that it was submitted to the Resident Council President for review with the group. Record review of Resident Council Minutes for 07/18/2023 revealed the following concerns: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676009 If continuation sheet Page 2 of 7 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 676009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Nursing - Resident down the hall's television loud passed midnight with door closed. Staff talked on their cellphones will providing patient care. 07/02/23 call light pressed at 01:30 Pm, answered at 2:45 PM. Resident's roommate moved into her room in the middle of the night. Requested fresh fruit, received canned fruit cocktail. Resident requested/circled apple juice on menu and served orange juice. Resident allergic to orange juice. Activities: Bingo money should be paid out at time of win.Dietary: Resident circled fresh tomato salsa on menu, was not received. Laundry: Resident's shirts have marks, new shirts with holes and lace shirt torn. Further review of the July 2023 minutes revealed Agenda Last meeting follow-up 1. All concerns from the previous meeting were addressed. New Business 2. All current concerns with the departments in the facility. However, there was no indication that the department heads returned the form to the AD, or that it was submitted to the Resident Council President for review with the group. Record review of the July 2023 Grievance Log revealed no logged grievances. Record review of the June 2023 Grievance Log revealed no logged grievances. June 2023; 6/19/23 Laundry over flowed. May 2023 reported books missing: Resolved: Yes 6/5/23. April 2023 none reported. Interview on 07/25/23 at 02:04 a.m. AD stated that only the resident council president attends the council meetings. She stated that she has been working with the facility for about 2 years. One year as the AD and the previous year as the AD assistant. She stated only the resident council president attends the group meetings. She stated that the other residents do not want to attend. She stated she tries to stress the importance of their attendance, but residents are not interested in participating. Two other residents were coming but one moved to independent living and the other has passed away. Interview on 07/25/23 at 03:33 p.m. DON stated that the current resident council president, has been the same president for many years. The other residents do not like to attend the meetings because the meetings are only always about the president. The other residents do not get a chance to voice or weigh in on their concerns and therefore stopped attending meetings months ago. Interview on 07/25/23 at 03:33 p.m. Administrator asked what they could do to encourage more residents to attend. She asked what the facility could do to replace the current president. The president brings with her a notebook full of complaints. The other residents do not get a change to voice their concerns or make comments. Interview on 07/26/2023 at 11:55 a.m. AD stated that she was responsible for reminding residents of the date and time of the resident council meetings and encouraging residents to attend. At the resident council minutes, she writes the minute notes and/or all the resident's concerns. She stated for the last few months only one resident has attended the resident council meetings. That resident usually brings written concerns to the meetings and the AD summarizes the notes in the group minutes for each month. Those minutes are distributed to the facility's department heads the following morning during the morning meeting. She stated that the minutes are also discussed during the Quality Assurance and Performance Improvement (QAPI) committee meeting held every 4th Friday of each month. Interview on 07-27-23 at 10:00 a.m. AD stated that she reminds residents of the group meeting the day before the meeting. She stated she then tells the CNAs of those residents who want to attend so the CNAs can get those residents ready for the day first. She stated when she completes the minutes her and the group members go over all the departments and address concerns. After the meetings, she meets with the Administrator to discuss each concern addressed. She stated July's group meetings were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676009 If continuation sheet Page 3 of 7 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 676009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the first given to the present administrator. She stated she gave the previous group minutes to the previous administrator who resigned. She stated that she does not go over any resident rights. She is not responsible for ensuring the concerns are resolved or grievances logs, or forms are completed. It is the administrator's responsibility to ensure the group's concerns are resolved. Interview on 07-26-23 at 03:06 p.m. Administrator stated she had only been in the administrator role for the last 5 weeks. She stated that she received the copies of the resident council minutes for the last 4 months today. She was aware that one of the residents from group had a dislike for the fruit cups. She stated she is not aware of what the outcomes were from the previous group complaints but would find out and share that information thereafter. She stated she was not aware of the dirty carpet, but the facility had a working carpet cleaner. She stated that one of the resident council members did not like roommates and was resistant to roommates. She stated that new admissions and room changes typically take place in the afternoon. She stated if a resident is admitted late at night from a hospital discharge, it would be possible for a resident to be moved into a shared room late at night. She stated the resident with the loud television was hard of hearing and she would see if the resident had or needed a hearing aid. She stated she would ask laundry if the resident had complained of damaged clothes and whether they were repaired. She stated the bingo time was changed to give the residents more time to play. She stated after resident council meetings the AD should create grievances and log them after every group meeting. She stated that she does not know why the AD had not created grievances or if that was a responsibility in the AD's job description. Each grievance related to the department it pertains to would be responsible for addressing, resolving, and following up with the resident or family member who made the complaint with the outcome. She stated thereafter it would be check off the grievance log as completed. She stated that she had only held one QAPI meeting since she became administrator and fruit cocktails and the loud television were the only group complaints brought up and discussed. She stated she provided follow ups to all the group grievances on 07/26/23 over the last 4 months. She stated that the SW will be responsible to ensure that the grievances are resolved and followed up on. Interview on 07-27-23 at 03:00 p.m. DON stated that she addressed grievances and in-serviced staff as needed. She was not aware of any outstanding grievances. She stated staff are in-serviced on resident rights monthly. She stated it is all the department heads responsibility to respond to the grievances. Grievances are also discussed during the monthly QAPI meetings. She stated that she addressed all the concerns that are addressed in the group meetings, but the resolve was not documented. She stated that her and the Administrator will come up with a tracking and resolve system to ensure grievances are addressed, resolved, and followed up on in a timely manner. She stated that moving forward the SW and AD will be responsible for ensured the grievances are resolved and residents informed of the resolve. Record Review of Resident Council Policy Statement's revised April 2017 date revealed 5. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the items(s) of concern. 6. The QAPI Committee will review information and feedback from the Resident Council as part of their quality review. Issues documented on council response forms may be referred to the QAPI Committee, if applicable (i.e., the issue is of serious nature or if there is a pattern, etc.) Records received: [NAME] Health Care Center Concern Forms Nursing dated 07/26/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676009 If continuation sheet Page 4 of 7 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 676009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement person-centered care plans for each resident's services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #22) reviewed for the develop and implement comprehensive care plans. - The facility failed to ensure Resident #22's comprehensive care plan included the resident's repeated refusal of Dronabinol (A medication used to treat nausea and vomiting). This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Findings included: Record review of Resident #22's face sheet undated revealed an [AGE] year-old female who admitted into the facility on [DATE]. The resident was diagnosed with fracture of the left Tibia (shin bone), dementia (mental decline not anormal part of aging), vitamin B deficiency, hypertension (elevated blood pressure), cardiac arrhythmia (irregular heartbeat), falls, and muscle weakness. Record review of Resident #22's admission MDS dated [DATE], revealed Resident #86's BIMS was scored as 11 which indicated her cognition was moderately impaired. Record review of Resident #22's Order Summary Report dated 07/26/2023 revealed Dronabinol Oral Capsule 2.5MG (Dronabinol) Give one capsule by mouth two times a day for nausea and vomiting. Order start dated 04/07/2023. Record review of Resident #22's Nurse MAR dated 07/01/2023-07/31/2023 revealed Resident #22 refused her Dronabinol on the following dates: July 2023 at 7:30AM: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 17, 18, 20, 22,23, 24, 25. July 2023 at 4:00 PM:1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24. Record review of Resident #22's Nurse Progress Notes revealed Resident refused her Dronabinol on July 2023: 1, 2, 3, 5, 6, 7, 16, 17, 18 and 24 by LVN A Record review of Resident #22's Nurse Progress Notes revealed Resident refused her Dronabinol on July 2023: 10 and 11 by LVN B Record review of Resident #22's care plans revision dated 07/18/2023 revealed no care plan for the resident's repeated refusal of Dronabinol. Observation on 07/26/2023 at 11:05 AM, revealed Resident #22 was in bed on her back with her head slightly elevated. Resident #22 had a wedge under her right shoulder. The resident refused to be interviewed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676009 If continuation sheet Page 5 of 7 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 676009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a phone interview on 07/26/2023 at 12:45 PM, the facility pharmacist stated Resident #22's Dronabinol was a routine order to be given twice daily. The pharmacist stated the order was not an as needed for nausea medication. In an interview on 07/26/2023 at 2:07 PM, LVN B stated she did document the attempts to administer the Dronabinol to Resident #22. LVN B stated Resident #22 often refused the medication. LVN B stated she explained the purpose of the medication to the resident. LVN B stated the resident still refused it. LVN B stated the resident's refusal could interfere with her treatment plan. In an interview on 07/26/2023 at 2:13 PM, LVN A stated she did attempt to give Resident #22 the Dronabinol. LVN A stated Resident #22 often refused the medication. In a phone interview on 07/27/2023 at 8:37 AM, Resident #22's physician stated he was aware that Resident #22 refused her Dronabinol. The physician stated Resident #22 had no negative affects from the refusal. As the interview continued, he stated he would not change her treatment plan because of her medication refusal. In an interview on 07/27/2023 at 12:00 PM, MDS LVN stated the purpose of the care plan was to direct the resident care. The MDS LVN stated the completion of the care plan was a team effort from all departments. The MDS LVN stated nursing participated by presenting resident problems that needed to be care planned as they presented. The MDS LVN stated the care plans were reviewed quarterly and in the daily morning meetings. As the interview continued, she stated the daily morning meeting was where the DON would present issues that needed to be care planned. The MDS LVN stated the facility also had weekly standard of care meetings where resident care concerns were addressed. The MDS LVN stated Resident # 22's repeated refusal of the medication should have been care planned. She stated the refusal could have been presented in the daily morning meeting or stand of care meeting by the DON. The MDS LVN stated she did not know why it was not addressed. The MDS LVN stated the risk to the resident of an inaccurate care plan was not providing guidance for the resident's care. In an interview on 07/27/2023 at 12:51 PM, the DON stated the purpose of the care plan was to ensure the resident care was based on the individualized need of the resident. The DON stated the MDS nurse was responsible for completion of the care plan. The DON stated the care plans were reviewed quarterly and as needed for any resident changes. The DON stated Resident #22's medication refusal should have been care planned. The DON stated she was not sure how the resident's medication refusal was missed. The DON stated she did not review the care plans to follow up for accuracy. The DON stated the risk of an inaccurate care plan was it could lead to a decrease in the resident functioning with poor health outcomes. The DON stated to prevent this in the future she would be more involved in reviewing the care plans for accuracy at least monthly. In an interview on 07/27/2023 at 1:28 PM, the Administrator stated the purpose of the care plan was to provide the plan for the resident's care. The Administrator stated the completion of the care plan was a team effort from different departments. The Administrator stated the MDS was responsible for the care plan accuracy. The Administrator stated monitoring the care plan for accuracy should be on a continuous basis. The Administrator stated the risk of an inaccurate care plan was failure to provide proper care to the resident. The Administrator stated the medication refusal should be care planned especially if it was continual. The Administrator stated to prevent this again we will develop a system for addressing issues in our daily morning meetings and every Friday's standard of care meeting. The Administrator stated she was not sure why they had not already been presented and addressed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676009 If continuation sheet Page 6 of 7 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 676009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered Revised dated December 2016, reflected in part Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems . Event ID: Facility ID: 676009 If continuation sheet Page 7 of 7