Health inspection·October 21, 2022

F 0686 - Level of Harm - Actual harm On 10/20/2022 at 2:08p.m., record review of wound management revealed no assessment was completed on resident #210's wound from the day of admission [DATE] to 10/20/2022. Residents Affected - Few On 10/20/2022 at 2:08p.m., record review of wound care for Resident #210 revealed Doctor's weekly visit that reflected one wound assessment was completed on Resident #210 done on 10/04/2022. On 10/20 2022 at 2:25p.m., record review of Resident 210's TARs (Treatment Administration Record) revealed the following: Stage 4 Pressure ulcer to sacrum - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. Stage 4 pressure ulcer to right hip - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. DTI (deep tissue injury) - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. Unstageable Pressure ulcer to left lateral ankle - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. Unstageable Pressure ulcer to left lateral leg - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. Unstageable Pressure ulcer to left lower buttock - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. Unstageable Pressure ulcer to right elbow - there was no wound care on 9/16/2022, 9/17/2022, 9/18/2022, 9/28/2022 and 9/29/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676155 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 676155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503 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 0686 On 10/21/2022 at 10:42 a.m. resident #210 was observed in bed, bed bound, non-verbal and ADL total dependent. Level of Harm - Actual harm Residents Affected - Few Interview on 10/21/2022 at 11:58 am. Wound Care Nurse stated when resident #210 was admitted on [DATE], she was on vacation and she would not know why the wound was not assessed and cared for. Wound Care Nurse stated usually the facility would have someone take care of resident's wound whenever she was not in the building because residents' wounds could get worsen if their wounds were not taken care of. Wound Care Nurse stated that she did not know who was responsible for wound care on those days she was not on duty. Interview on 10/21/2022 at 09:32 am Wound Care Doctor stated he was unable to see Patient #210 because she might have been admitted on the days, he did not visit the facility. Wound Care Doctor stated that whenever there was admission with a wound, the wound care nurse would take a picture of the wound and send to him for orders and if he was made aware of the resident's situation, he would have given orders for the wound care. On 10/21/2022 at 1:02 p.m. record review of facility policy revealed: 1. Policy titled 'Wound Evaluations' dated 06/01/2022 reads, Evaluation of wounds will be performed on admission, weekly and on discovery. 2. Policy titled 'wound documentation' dated 06/01/2022 reads, on admission and/or discovery, the clinician initiates the wound documentation process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676155 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 676155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities for one (Resident #103) of five residents reviewed for enteral nutrition. Facility failed to ensure the Osmolite (nutritional supplement) was not expired before administering it to Resident 103. This failure could place the resident at risk for feeding drug interactions, malnutrition, dehydration, and illness. Findings include: Review of Resident #103's face sheet revealed an [AGE] year-old male admitted on [DATE] with the following diagnosis: dysphagia (difficulty swallowing), aphagia (refusal or inability to swallow), cough, feeding difficulties, gastro esophageal reflux disease (back flow of stomach acid). Review of Resident #103's admission MDS dated [DATE] revealed he had a BIMS score of 9 out of 15 which indicated his cognition was moderately impaired. Resident #103 required extensive assistance of one to two staff assist with bed mobility and required extensive assistance of one to two staff assist for transfers, dressing and toilet use. Resident # 103 was incontinent of bladder and bowel. K0100. Swallowing Disorder. C. Coughing or choking during meals or when swallowing medications. K0510. Nutrition approach, While a Resident, B. Feeding tube. Review of Resident #103's physician orders dated [DATE]-[DATE] revealed an order start date of [DATE] open ended for Osmolite 1.2 385cc via bolus QID Four Times A Day: 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of Enteral Administration history for Resident #103 revealed 4 bolus feedings administered on [DATE] & 1 bolus feedings administered [DATE] at 9:03 am. Observation and interview on [DATE] beginning at 11:18 a.m. revealed LVN A walked into Resident #103's room and stated she was going to prepare his tube feeding. The surveyor observed 8 containers of Osmolite (8 fluid ounces) sitting on top of a dresser in Resident # 103's room. LVN A removed 2 of the 8 containers of Osmolite and poured them into 2 different measuring cups. After preparing Resident # 103's tube feeding, the surveyor asked LVN A if she was ready to administer the tube feeding and LVN A stated yes. The surveyor stopped LVN A and asked her to look at the expiration dates on the Osmolite containers. When LVN A looked at the 8 Osmolite containers on top of Resident # 103's dresser she stated the dates on all of the containers had expired on [DATE] and she did not think to check the dates before preparing the tube feeding. LVN A stated she was not going to administer the expired Osmolite because the risk of doing so could cause the resident to have an upset stomach, nausea, or vomiting. Interview on [DATE] at 11:36 am ADON stated the Osmolite should not be expired and stated she did not have a response for it being expired in Resident # 103's room and on the shelf in the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676155 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 676155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room to be used. ADON stated it was the responsibility of the nursing staff to review medication prior to administration, including but not limited to the expiration date. ADON stated ingestion of expired enteral nutrition could cause Resident # 103 to get infections, have allergic reactions, affect their vital signs and multiple other things could happen when giving expired enteral feedings. Interview on [DATE] at 3:36 pm CSD stated expired tube feeding formula should not be used because the risk would be less effective like with any medication. The CSD stated all nurses had to check the expiration dates before giving any medications. Record review of the NF policy on Medication Management Program revised on [DATE] read in part . The facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. 15. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676155 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 676155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored properly in accordance with professional standards of practice in one of two facility medication rooms (Unit 100 Hall), reviewed for labeling and storage of drugs and biologicals, in that: Medication room on Unit 100 Hall had expired medications. These failures placed residents in Unit 100 Hall at risk of receiving expired medications and adverse reactions. Findings Include: Observation on 10/19/22 at 11:28 a.m. on Unit 100 Hall inside the medication room revealed the following expired medications: Osmolite 1.5 CAL (nutritional supplement) with an expiration date of 10/01/22. Interview on 10/19/22 at 11:31 a.m. LVN A stated she was not aware of the expired medications in the medication room. LVN A stated the nurses on each unit were responsible for ensuring there were no expired medications in the medication rooms. LVN A stated the risk of having expired medications in the medication storage room was that it could have been given to a resident and caused them to be sick. Interview on 10/19/22 at 11:36 a.m. ADON stated all the nurses was responsible for checking to ensure there were no expired medications in the medication storage rooms. The ADON stated expired medications given to the residents will not have the correct potency and could cause the resident to get infections, have allergic reactions, affect their vital signs and multiple other things could happen when giving expired medications. Record review of the NF policy on Medication Management Program revised on 07/13/2021 read in part The facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. 15. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676155 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 676155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Courtyards at Pasadena 4048 Red Bluff Road Pasadena, TX 77503 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide safe and sanitary environment and to help prevent the development and transmission of diseases and infections for 1 (Residents #22) out of 7 residents reviewed for infection control. Residents Affected - Few Facility failed to ensure the Resident #22's foley bag and tubing was off the floor. This failure could place residents at risk of cross contamination and infection. Findings include: On 10/21/2022 at 11:56 a.m. review of resident #22's face sheet showed resident was a [AGE] years old male admitted to the facility on [DATE]. His diagnoses include pressure ulcer of sacral region stage 4, altered mental status, paraplegia (paralysis of the legs and lower body), hypertensive chronic kidney disease, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. On 10/21/2022 at 10:29 a.m. Resident #22 was observed in bed, dialysis was in progress and dialysis nurse was sitting by the bedside. Foley bag was observed hung on bed rails, however, the foley bag and the tubing was resting on the floor. Interview on 10/21/2022 at 10:58 a.m. Nurse A stated she (Nurse A) did not always come into the room whenever the dialysis was going on. Nurse A stated it was an infection control concern, bacterial from the floor could go through the bag and up through the tubing into a resident and cause infection. Interview on 10/21/2022 at 1:28 p.m. Clinical Services Director stated the foley bag on the floor was an infection risk for the patient. Clinical Services Director stated she was in the process of performing in-service for the employees in order to correct the deficient practice. Facility Policy provided titled 'Catheter / Urinary Catheter, Use of' dated 2011 did not address foley catheter care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676155 If continuation sheet Page 7 of 7