Health inspection·February 1, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm 01/21/2024 Category: ADLs Functional Status/Rehabilitation Potential Resident #119 requires assistance with all ADL's r/t: impaired cognition and Dx of CVA w/Rt hemiplegia. Goal: Long Term Goal Target Date: 04/21/2024- Resident #119 will maintain a sense of dignity by being clean, dry, odor free, and well-groomed over next 90 days. Approach: Start Date: 01/21/2024 staff will assist during bath/shower to the extent necessary while allowing Resident #119 to participate as much as they are able. Residents Affected - Some The resident's Care Plan did not include the residents frequent shower refusals. Record review of residential Shower Book dated 01/01/2024-01/31/2024 noted resident refused on 01/12, 01/19, 01/24, 01/31. The log showed 01/08, 01/22, 01/26, 01/29, were blank and the resident received a Bed bath on 01/17, and a Shower on 01/15. Record review of Point of Care History dated 01/01- 02/01/2024 noted Resident #119 received one bath on 01/15/2024. Interview on 01/31/2024 at 1:05 PM with LVN A. She said every other day residents got showers and it was either Monday, Wednesday, Friday, or Tuesday, Thursday, Saturday. She said Resident #119 refused to shower a lot. She said she needed to write a note about him refusing to take a shower today. She said she did not see a note for his refusal . Interview on 01/31/2024 at 1:08 PM with the Shower tech/CNA. She said residents got showers every other day. She said usually a nurse would document that the resident refused to take a shower. She said there was a shower book of hers where she logged when a resident refused a shower/bath. She said she did not like to write refuse because then the later shifts would not attempt to ask the residents if they wanted a shower. She said she just asked Resident #119, and he refused to take a shower and he refused often to take a shower. She said she can usually talk him into taking a shower about every 2 weeks. She said one shower a week was not enough. She said infections could develop if a resident did not take a shower enough. Interview and observation on 01/30/2024 at 1:57 PM with Resident #119. The resident was lying in bed watching TV, water on bedside table, and call light on right side of bed. He was dressed in a blue shirt. There was a smell of body odor on the resident. He said staff treated him well, but he said he had not had a bath since he had been here. He said he did not know how long he had been at the facility. He said he thought he got the treatment and services he needed minus the showers. Interview and observation on 01/31/2024 at 1:03 PM with Resident #119. He said he had refused to take a shower twice while at the facility. He said he did not know how often he was supposed to get a shower. The resident still had a smell of body odor about him. Interview on 02/01/2024 at 10:57 AM with Resident #119. He said he refused a shower yesterday. Interview on 02/01/2024 at 11:05 AM with the Shower tech/CNA. She said sometimes residents just did not want a shower with her, but they do with the CNA at nighttime. She said she told the nurse for that shift whenever the resident refused their shower. She said Resident #119's shower day was yesterday, and he refused. She said she thought refusing showers should be on his care plan. She said she did not like to write refuse in the log or kiosk so that others will try and get them showered. Interview on 02/01/2024 at 12:20 PM with LVN B said Resident #119 had not been at the facility long, but every time he was asked about a shower, he only accepted one shower. She said he had been here (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 02/01/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for less than a month. She said it was a problem that he was not getting showers. She said the facility notified the family. She said his refusals were referred to the ADON. She said if a resident refused to shower, then another nurse talked with him. She said refusal of showers should be in the Care Plan . Interview on 02/01/2024 at 12:25 PM with LVN A said she did not know how often Resident #119 refused his showers. She said the shower tech told her he refuses often. She said shower refusals should be in the resident's Care Plan if a resident refused often enough . Interview on 02/01/2024 at 12:20 PM with the MDS Coordinator. He said regarding showers and baths, there was a Care Plan for ADLs that included hygiene. He said once it was determined there was an issue with something, then a behavioral plan for resistance or refusal of care was added to the Care Plan. He said shower refusals were added to the Care Plan when there was a history of that behavior and when he became aware of it. He said when they become aware and that it is not a onetime incident, the behavior would be added to the resident's Care Plan. He said he is worked at the facility for 10 years and his role at the facility was MDS coordinator. He said he worked Monday-Friday, 8 AM-5 PM. He said he was familiar with Resident #119. He said he knew he was admitted in the beginning of January for a stroke, and he did his comprehensive care plan. He said he became aware of today that he was refusing his showers after this state surveyor had requested shower logs for the resident. He said he did not know how long the resident had refused showers. He said policy or procedure for shower refusals was once staff were notified, the Clinical Interdisciplinary team meet and look at the incident/behavior from care standpoint. They notified RPs, and PCP, and arranged for a Care Plan meeting with the resident and try to determine the cause of refusal and work at resolving the issue. He said he did not know why he was not told sooner. He said when he did the resident's initial MDS that shower refusal behavior was not present. He said he was last in-serviced on care plans last year, about Springtime. He said the DON was responsible for ensuring Care Plans were implemented. He said the risk to residents was there was potential for them not receiving adequate care, and hygiene there could be adverse effects of health and skin. He said the worst thing that can happen to the resident when proper protocols are not practiced was the resident could receive inadequate care, and there was potential for injury. He said he thought the failure occurred in this situation, for him due to a lack of communication. In an interview on 02/01/2024 at 12:29 PM with the DON, she said she worked at the facility since 12/18/23. She said she worked 7 AM- 4 PM, Monday - Friday. She said she was not familiar with Resident #119. She said she had not heard anything negative, no complaining, and his documents said he was alert, but when talking with him, you can see he needed help. She said she mostly read papers, and refusals of the residents. She read over orders, printed reports on refusals of medications and supplements. She said she made sure Care Plans were accurate regarding refusal of medications or supplements. She said she depended on her ADONs for help. She said she was responsible for reports and the follow up on the reports. She said policy for Care Plans was if the resident was new, they needed an initial Care Plan, and the MDS Coordinator entered the Care Plans. She said she got more involved when there was a fall, refusal of medications/supplements, and wounds. She said if someone had an episode, or psychological issues then she would add that to the Care Plan. She said if a resident's behavior was brought to her attention, then the facility would Care Plan for that. She said there were a lot of refusals, but they are not shown in the documentation. She said she had heard recently in the last couple of days about Resident #119 refusing showers. She said she and the MDS Coordinator talked about Resident #119, and by printing out the report they saw that the resident refused, and it needed to be on his Care Plan. She said they are going to (continued on next page) 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 02/01/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete try other people to shower him. She said she would change the process of the shower tech to tell her personally about residents who had shower refusals. She said the process was that the Shower Tech should notify the ADON when there was a refusal for showers. She said she was last in-serviced on Care Plans last month. She said the nurse management team was responsible for ensuring protocol was followed regarding including refusals to the resident's Care Plan. She said the risk to the resident if policy or protocol was not followed was the resident may not get the best care. She said the worst thing that can happen to the resident when proper protocols are not practiced was the resident could have skin breakdowns. She said she thought the failure occurred because there was a breakdown in communication. She said it should go from the Shower tech to the nurse, from the nurse to the ADON, and from the ADON to the clinical team. 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 02/01/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement . The facility failed to prevent the following. 1. A Plastic Container of American Cheese dated 1/27/24. 2. A Plastic Container of Mozzarella Cheese had no label and was not dated. 3. A Plastic Container of Powdered Cheese had no label was not dated. 4. A Plastic Container Cream Mexicana Sour Cream with expiration date 1/13/24 5. A Plastic Container of Hard-Boiled Eggs, no label dated 1/15/24. These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 01/30/24 at 6:30 AM revealed that leftover foods were not discarded prior to the use by date. 1. A Plastic Container of American Cheese dated 1/27/24. 2. A Plastic Container of Mozarella Cheese had no label and was not dated. 3. A Plastic Container of Powdered Cheese had no label was not dated. 4. A Plastic Container Cream Mexicana Sour Cream with expiration date 1/13/24 5. A Plastic Container of Hard Boiled Eggs , no label dated 1/15/24. Interview with the AM [NAME] on 01/30/24 at 6:35 AM he stated that the leftover food stored in the refrigerator should have been used or discarded prior to use by date. (continued on next page) 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 02/01/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Record review of facility's policies and procedures for food and safe handling dated 6/20/23 read in part .8. Foods are labeled to. identify container contents and the date it was prepared. Food items are stored in disposable, tightly covered containers, or sealable Residents Affected - Some plastic bags. Items will be stored for three (3) days. Expired and unlabeled items will be discarded. 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 02/01/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Residents Affected - Many Food and Nutrition Services. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 01-30-24 at 7:10 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and the door was wide open. In an interview on 01-30-23 at 7:20 am, with the AM Cook, he stated that the dumpster doors always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Record review of facility's Nutrition Policies and Procedures on waste disposal dated 6/20/23 read in part.1. Waste will be disposed. of in a manner to prevent transmission of disease, nuisance or breeding place for insects and feeding places for rodents and other. mammals. Procedures.5. Always cover waste containers and close dumpster's door. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676155 If continuation sheet Page 7 of 7