Health inspection·November 10, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 11/07/23 at 10:32 a.m., Resident # 60's incontinent brief change provided by CNA M reflected brief was saturated from front to back. The inside of the incontinent brief was brown, and the wet indicator was faded entirely. During an interview on 11/07/ 23 at 12:14 p.m., CNA M said she was Resident #60's aide and came to work at 6:00 a.m. CNA M said she had not provided incontinent care for Resident #60 since she arrived this morning because the night shift changed Resident #60, and she was not getting her out of bed this morning. CNA M said the aides usually changed residents who were left in bed after breakfast. She stated she had not gotten to Resident #60 to change her incontinent brief until 10:30 a.m. because she was busy. CNA M said Resident # 60's incontinent brief was wet with urine from front to back, and the wet indicator lines faded out. CNA M said if she did not change Resident # 60 timely, she could develop rashes and wounds. CNA M said she was supposed to make rounds every two hours for incontinent care and change the resident if the resident was wet. CNA M said the charge nurse monitored the aides by marking random rounds, and the ADON monitored the charge nurses. She said she had an in-service on rounding and incontinent care. During an interview on 11/08/23 at 1:39 p.m., the DON said CNA M should make rounds every two hours, check on residents, and provide incontinent care for residents who needed care. The DON said it was not the facility protocol to change only the residents who were getting up in the morning. CNA M had to change the residents she would be getting up first and then use her discretion on whom CNA M would change next. The DON said Resident #60 could have skin irritation if left in a wet brief. The DON said the charge nurse monitored the aides to make sure they were providing care to the residents. The DON said the ADON monitored the nurses, and the ADON should have the answer to how she monitored the nurses for care. During an interview on 11/09/23 at 1:27 p.m., ADON said CNA M should make rounds every two hours and as needed to provide incontinent care for Resident #60. ADON said it was unacceptable not to change Resident # 60 because she was not being assisted out of bed that morning. ADON said Resident #60 could sustain skin breakdown, skin irritation, skin infection, and UTI. ADON said when the wet indicator faded out, and the brief was saturated, it meant Resident #60 had not been changed for some time. ADON said the charge nurse monitored the aides by making random rounds, and ADON LT said she monitored the charge nurses by making random rounds and asked the residents if they were changed . 2. During an observation on 11/07/23 at 10:45 a.m., revealed Resident #60's skin from her knees down to her feet were dry and flaky, and there was a substantial amount of flaked dry skin on Resident #60's mattress. During an interview on 11/07/23 at 11:00 a.m., CNA P said she saw Resident #60's mattress had a lot of dry skin. CNA P said Resident #60's aide should have applied lotion on Resident #60's skin on shower days and any time Resident # 60's skin was dry. She stated that it was to prevent it from flaking off, such as the dry flaked skin on Resident #60's mattress. CNA P said Resident #60's skin could break down if dry skin was not prevented or treated . During an interview on 11/07/23 at 11:04 a.m., Resident #60 said the nurses should apply lotion on her skin after showering on Tuesday, Thursday, and Saturday. She stated lotion should be applied when her skin was dry on the days she did not shower, but sometimes the nurse did not apply any cream on her . During an interview on 11/07/23 at 12:16 p.m., CNA M said Resident #60's skin was dry and flakey (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 2 of 5 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 676194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason Creek Transitional Care of Katy 21727 Provincial Blvd Katy, TX 77450 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few from her knees down to her feet, and there was a lot of flaked skin on Resident #60's mattress. CNA M said Resident #60 was showered on Tuesday, Thursday, and Saturday, and the aide who showered Resident # 60 should have applied lotion on her . CNA M said if Resident #60's skin continued to fall off, she could have a skin tear or a wound. CNA M said the nurse made random rounds to monitor the aides. CNA M said she had not applied any lotion on Resident #60's legs before now , but she would apply cream later. CNA M said she had skills checked off on shower. During an interview on 11/08/23 at 2:49 p.m., the DON said she would talk to Resident #60's provider about applying lotion on Resident #60's skin. The DON said Resident #60 could have skin break down if her skin continued to flake off. During an interview on 11/09/23 at 1:51 p.m., ADON said Resident #60 should get a shower at least three times a week, and the aide who showered Resident #60 should apply lotion on her skin on her shower days and as needed. ADON said the aides should often lotion Resident #60's legs to prevent dry skin flakes. ADON said Resident #60's skin could develop wound and infection if the skin opened. Record review of the facility policy on bath, and shower, revised 05/2007, read in part . this facility policy to promote cleanliness, stimulate circulation and assist in relaxation . procedures: dependent residents: #6. Apply lotion FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 3 of 5 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 676194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason Creek Transitional Care of Katy 21727 Provincial Blvd Katy, TX 77450 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, interview, and record review, 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 in that: -The facility failed to dispose of expired food items and keep Scoops stored outside of food bins. These failures could place residents at risk of food borne illness and diseases. Findings include: Observation of the facility's kitchen and interview on 11/07/23 between 8:30 am and 8:40 am with the Food Service Manager revealed the following: Sliced American Cheese in a plastic container dated 10/27/23 stored in the refrigerator. Sliced Swiss Cheese in a plastic container dated 10/03/23 stored in the refrigerator. Cheese Parmigiana in a plastic container dated 9/07/23 stored in the refrigerator. Scoops for bulk food were left in the sugar and flour bins stored in the storeroom. Interview with the Dietary Food Service Manager on 11/07/23 at 8:35 AM, stated that the plastic containers with cheese should have been used or discarded prior to the used by date. The Scoops for bulk food should be stored in the storeroom, it was not to be stored in the food bin. Interview with the Food Service Manager on 11/07/23 at 9:00 AM, she stated she was responsible for training staff on labeling and storage requirements, ensuring dietary requirements were met. She further stated she would in- service the dietary staff on refrigerated storage, practices to maintain safe refrigerated storage, labeling, dating, and monitoring refrigerated food. Record review of facility's Policy Food Safety Requirements dated 03/2023; Policy: Food will be stored in area that is clean, dry, and free from contaminants. Policy read in part. Leftover foods will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Record review of 2017 Federal Food Code revealed that leftover food is used or discarded within 7 days. Scoops must be provided for bulk foods such as sugar, flour, and spices. Scoops are not to be stored in food or ice containers. Scoops are washed and sanitized on a regular basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 4 of 5 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 676194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason Creek Transitional Care of Katy 21727 Provincial Blvd Katy, TX 77450 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, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. Residents Affected - Many -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 include: Observation on 11-07-23 at 9:00 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 top lid was wide open. Interview on 11-07-23 at 9:05 am, with the Food Service Manager, she stated that the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Record review of facility's, undated, policy and procedure Dispose of Garbage and Refuse reflected all garbage will be disposed of daily and as needed throughout the day. Procedure:. all dumpster lids and doors shall be closed or sealed at all times. Trash will be deposited into containers outside the premises. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 5 of 5