Health inspection·December 12, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the MDS Nurse assisted with completion. If a care plan needed to be updated the MDS Nurse would complete the update. Every morning she reviewed the change of conditions and order reports. When the physician orders were changed then she knew to update the care plan. She would not have known to update the care plan without an order change . In an interview on 12/10/24 at 3:29 PM the NP stated she may have put in Resident #66's order incorrectly. She sent an order for the midline insertion. She was going to speak with the DON because it should have been a batch order, the monitoring and care of the midline would show up in the physician orders. In an interview on 12/10/24 at 3:23 PM the DON stated Resident #66's physician order was entered by the NP, but the NP did not notify nursing staff, the DON, or put in standing orders for monitoring. The physician orders for monitoring and care were not in the system so the care plan was not updated. It was important to have physician orders to make sure staff were aware how to care for Resident #66's midline. The midline dressing should be changed every 7 days or if it was visibly soiled. In a continued interview the DON, she said the DON and the ADON were responsible to monitor the physician orders and care plans, they had been focused on other issues. The DON and the ADON review new orders and change of condition daily, then the care plan will be updated based on those changes . Record review of the policy and procedure entitled Comprehensive Person-Centered Care Planning dated revision/review date(s):1.2022; 12.2023 read in part .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . to provide effective and person-centered care that meet professional standards of quality care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 2 of 13 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 12/12/2024 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 0694 Provide for the safe, appropriate administration of IV fluids 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 review the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 (Residents #66) of 1 Residents reviewed for peripheral intravenous care. Residents Affected - Few The facility failed to ensure Resident #66 had a physician order or care plan for the care and monitoring of her midline. The facility failed to ensure Resident #66's midline dressing was changed every 7 days per facility policy. The failures placed residents at risk of developing an infection. Findings included: Record review of Resident #66's face sheet dated 12/2024 revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of pressure ulcer of sacral region stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) dementia, abnormal weight loss, chronic kidney disease, constipation, dysphagia (difficulty or discomfort swallowing), cognitive communication deficit, acute osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection), and cystitis (inflammation of the bladder). Record review of Resident #66's admission MDS dated [DATE] revealed she did not have a BIMS score. Resident #66 was not admitted on antibiotics. Record review of Resident #66's physician orders dated 12/2024 revealed on .Piperacillin-Tazobactam in Dex Solution 2-0.25GM/50ML dated 11/27/24 insert midline for IV tx for osteomyelitis dated 11/29/24. Resident #66 did not have physician orders to address the care or monitoring of the midline and bandage change. Record review of Resident #66's care plan dated 11/2024 revealed I am on Piperacillin-Tazobactam in Dex Solution 2-0.25 GM/50ML Use 2.25 gram intravenously every 8 hours for sacral wound osteomyelitis for 6 Weeks via midline. Resident #66's care plan did not address the care or monitoring of the midline and bandage change. Observation on 12/10/24 at 2:55 PM Resident #66's midline dressing change by LVN B revealed the midline site without redness, drainage, or swelling. During the dressing change, the nurse did not clean the site first with alcohol, instead cleaned with betadine first, cleaning the site back and forward, instead of starting at the site moving in a circle away from the site. In an interview on 12/10/24 at 1:42 PM LVN B said after observing the dressing to Resident #66's midline read 11/30. LVN B said the dressing to the resident's midline was outdated. LVN B said he believed the midline dressing was supposed to be changed every 2 weeks, but he would have to confirm with the DON or the ADON. LVN B said it was important to change the resident's midline when it was due to be changed to prevent infection. In an interview on 12/10/24 at 1:50 PM the DON said Resident #66's midline dressing was supposed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 3 of 13 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 12/12/2024 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 0694 be changed every 7 days and PRN for infection control. Level of Harm - Minimal harm or potential for actual harm Interview on 12/11/24 at 3:26PM LVN B said he did not think he did well when changing Resident #66's midline dressing because he did not clean the resident site first with alcohol in a circular motion moving away from the site. LVN B said this was supposed to be done to avoid re-introducing bacteria to the site. LVN B said the site should have been cleaned with alcohol first and then betadine. LVN B said the last time he received an in-service on midline dressing change was about a year ago at another facility. LVN B said the ADON informed him that he had to clean the midline dressing site first with alcohol followed with betadine. Residents Affected - Few In an interview on 12/10/24 at 2:52 PM the MDS Nurse stated the DON initiated the care plans and the MDS Nurse assisted with completion. If a care plan needed to be updated the MDS Nurse would complete the update. Every morning she reviewed the change of conditions and order reports. When the physician orders were changed then she knew to update the care plan. She would not have known to update the care plan without an order change . In an interview on 12/10/24 at 3:29 PM the NP stated she may have put in Resident #66's order incorrectly. She sent an order for the midline insertion. She was going to speak with the DON because it should have been a batch order, the monitoring and care of the midline would show up in the physician orders . In an interview on 12/10/24 at 3:23 PM the DON stated Resident #66's physician order was entered by the NP, but the NP did not notify nursing staff, the DON, or put in standing orders for monitoring. The physician orders for monitoring and care were not in the system so the care plan was not updated. It was important to have physician orders to make sure staff were aware how to care for Resident #66's midline. The midline dressing should be changed every 7 days or if it was visibly soiled. In a continued interview the DON said, the DON and the ADON were responsible to monitor the physician orders and care plans, they had been focused on other issues. The DON and the ADON review new orders and change of condition daily, then the care plan will be updated based on those changes. In an interview on 12/11/24 at 2:33PM the DON said the ADON was also the Wound Care Nurse. The DON said LVN B had only been working at the NF for a few months. The DON said she completed training with LVN B on midline dressing changes with return demonstration. The DON said when cleaning the site of the midline, the nurse was supposed to clean the site with alcohol first to ensure the skin was clean and then clean with betadine/iodine for infection control. Record review of the Nursing facility policy on Midline Dressing Changes/Intravenous Therapy dated 08/30/2024 revealed in part: .The purpose of this procedure is to prevent catheter-related associated with contamination, loosened or soiled catheter-site dressings .Change midline catheter dressing every 7 days, or if it is wet, dirty, not intact, or compromised in any way .use aseptic technique when changing a midline catheter dressing .If using alcohol and iodine packages .use alcohol swabs first. Clean in concentric circles away from the catheter .Repeat the same process with iodine swabs. Do not remove iodine from the skin . Record review of the Nursing facility policy Physician Orders dated 11/13/18 revealed in part: It is the policy of this facility to accurately transcribe and implement orders in addition to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 4 of 13 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 12/12/2024 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 0694 Level of Harm - Minimal harm or potential for actual harm medication orders (treatment, procedures) only upon written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care 6. Medication, treatment, or related orders are transcribed in the eMAR, eTAR accurately and verified. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 5 of 13 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 12/12/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, and administering medications for 1 (Resident #78) of 8 residents reviewed for pharmaceutical services. -Medication Aide A failed to administer the correct dosage for Resident #78's transdermal nicotine patch. -Medication Aide A failed to rotate the transdermal nicotine patch on Resident #78's body. This failure placed the resident at risk for skin irritation and not receiving the full intended therapeutic dosage of the medication. Findings: Resident #78 Record review of Resident #78's face sheet dated 12/12/24 revealed a [AGE] year-old male admitted to the NF on 10/22/24 with the diagnoses that included the following: fatigue, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when stomach acid or bile {fluid produced by the liver and stored in the gallbladder that helps with digestion} that irritates the food pipe lining, respiratory failure, and hypertension (high blood pressure). Record review of Resident #78's admission MDS dated [DATE] reflected a BIMS score of 13 indicating that resident cognition was intact. Record review of Resident #78's December 2024 Physician Oder Summary Report reflected the following order: -Dated 11/13/24 Nicotine Patch 24-hour 14mg/24HR apply 1 patch trans-dermally (medication that is absorbed through the skin into the blood stream) one time a day for smoking cessation and remove per schedule. Record review of Resident #78's MAR for the month of December 2024 reflected that the resident was being administered mediations per physician orders. Record review of Resident #78's Comprehensive Care Plan dated 10/23/24 reflected that the resident was being care planned for refusing rotation of the nicotine patch date initiated 12/12/24 that included the following interventions: -Allow to make decisions about treatment regimen, to provide sense of control. -Educate resident/family/caregivers of the possible outcome (s) of not complying with treatment or care. -Encourage resident to comply with rotation of nicotine patch to minimize risk of skin irritation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 6 of 13 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 12/12/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 12/10/24 at 9:38AM of Medication Aide A administered the medication nicotine transdermal patch 7mg to Resident #78. Medication Aide A removed the old patch on the resident's left upper arm and placed the new patch on the same area of the resident's left upper shoulder. In an interview on 12/12/24 at 10:30AM Medication Aide A said she made a mistake when administering Resident #78's nicotine patch by not administering the correct dosage. Medication Aide A said she administered to the resident 7mg instead of the ordered dose 14mg. Medication Aide A said it was important to rotate the resident's nicotine patch to avoid the risk of skin irritation. Medication Aide A said the reason she did not rotate the resident's nicotine transdermal patch was because the resident refused for it to be rotated. Medication Aide A said because she did not administer the correct dosage, the medication would not be as effective. Medication Aide A said she made a mistake. Medication Aide A said the 6 rights to use when administering medications were the following: the right patient, right medication, right dosage, right time, right route, and right order. Medication Aide A said the last time the pharmacist was at the facility, it was approximately a week ago, and observed her during medication pass. In an interview on 12/12/24 at 11:40AM the DON said the reason the medication patches should be rotated was to avoid any skin irritation. The DON said she would be conducting a medication in-service with Medication Aide A. Further interview with the DON, she said it was herself and the other ADON's that observed medication passes with the nursing staff and that the pharmacist came to the NF once a month to observe medication pass along with checking the medication carts. The DON said she just learned that Resident #78 was refusing for his nicotine transdermal patch to be rotated. The DON said she would provide a copy of Medication Aide A training and her last medication observation. Record review of Medication Aide A last observation of medication pass signed by the DON on 11/06/24. Interview on 12/12/24 at 2:26PM with Resident #78 said he never refused for his nicotine transdermal patch to be rotated. The resident said he did not have any problems with the staff rotating his patch on his body. Record review of the NF policy on Medication Administration---General Guidelines revised 11/13/18 reflected in part: .Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, the nurse/medication aide will verify the MAR with the order in the medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 7 of 13 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 12/12/2024 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, record review 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 ensure food was labeled and dated. - The facility failed to ensure that food was off the floor in the dry food area. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation on 12/10/2024 at 08:53 AM, revealed in 1 of 1 walk in refrigerator a metal bowl with clear plastic wrap with a with no date or item description. [NAME] B took the bowl out of the refrigerator. Observation on 12/10/2024 at 08:56 AM, revealed on the floor of 1 of 1 walk in pantry a 24-ounce (oz), less than a 25 precent (%) full bottle of syrup dated 3/17 between 1 of 3 shelves on the right side of pantry and an 1-oz bag of chips was observed on the floor between the shelves near the wall. [NAME] A removed the syrup and bag of chips from the dry food storage area. Observation on 12/10/2024 at 08:59 AM, revealed 1 of 1 standalone refrigerator had 9-glasses of milk with lids sitting on a tray with no label. In an interview on 12/10/2024 at 08:50 AM, [NAME] A stated that he would oversee the kitchen until the Dietary Manager (DM) came on shift, and she would be on her way. During the initial tour of the kitchen in 1 of 1 walk-in refrigerator, [NAME] A stated he was not aware of what was in the metal bowl. He turned to [NAME] B and asked what was in the bowl. [NAME] A stated he had not seen the syrup on the floor in the dry food storage areas. He stated he does not know how long the syrup could have been there. When asked could it have been there since March 17th of this year, he stated it could have, but if he had seen it, he would have gotten it up. He stated he was not aware of how long the bag of chips were on the floor. In an interview on 12/10/2024 at 08:53 AM, [NAME] B stated that the food item in the metal bowl was beef tips she had been marinating from a left-over dinner. When asked what day the beef tips were prepared, [NAME] B stated, the other day. When asked why they were in the refrigerator undated, she stated that she would throw them out. In an interview on 12/10/2024 at 08:56 AM, [NAME] A stated that the milk in the 1 of 1 standalone refrigerator was poured the night before in preparation for the morning meal. He stated that he there was a label on the milk tray. [NAME] A looked but could not find a label. [NAME] A stated there should have been a labeled on the tray so that they knew when the milk was old and should not be served to residents that would make them sick. [NAME] A stated that the label was on a tray in the dish area and he had just changed out the trays after milk had spilled on the tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 8 of 13 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 12/12/2024 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 In an interview on 12/10/2024 at 12:25 PM, Dietary Manager (DM), stated that the meat in the metal bowl were beef tips, prepared for residents on 12/08/2024. She stated that food not prepared and not cooked was only to be stored for 3-days and thrown on the 3rd day. She stated that 12/10/2024 was the last day for the food to be stored and it was to have been thrown away. She stated it was her expectation when there was left over meat from a meal that it be thrown away the same day. She stated that [NAME] B told her that the beef tips were saved to serve as an alternative meal if needed, and the date and description of the item was written on the label. She stated that 12/10/2024 was the 3rd day and the day the item would have to be thrown away. She stated that she was not aware of the items on the floor in the dry storage area. She stated that [NAME] A told her that he was in the process of relabeling the milk when the State surveyor entered the kitchen and had not relabeled the milk tray because he toured the kitchen with the surveyor. She stated it was her expectation that no interrupt should deter staff from labeling food items and all food items were to be labeled before storing. She stated it was also her expectation if staff saw food items on the floor that they would immediately throw them away. She stated the importance of labeling food was to ensure that residents were not served outdated or expired food that could make them sick. She stated that importance ensure food items were off the floor were to ensure that residents were not served contaminated and expired food that would make them sick and to ensure not to attract pests. In an interview on 12/12/2024 at 02:14 PM, with the DON and Operations Manager (OM) the OM stated that all food should be labeled to know when the items expired, and to know when it would expose danger to residents. The DON stated failure to label could cause the food not to taste good and make the residents sick. Record review of facility menu dated Saturday, Week 1, revealed that braised beef tips with gravy were served for lunch (12/07, 2024). Record review of facility in-service dated 12/10/2024 at 01:00 PM, with the dietary department revealed: Staff make sure no chip, or item are on dry storage floor. If there is, please put in the trash immediately. Do not put back on shelf. Record review of facility policy titled Control Policy/Procedure and dated 08/2007, revealed: Section: Dietary Services Subject: Food Storage POLICY: It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. PROCEDURES: 2. All foods or food items not requiring refrigeration shall be stored at least six (6) inches above the floor and at least eighteen (18) inches from sprinkler heads, on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents, or vermin. All packaged food, canned foods, or food items stored shall be kept clean and dry at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 9 of 13 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 12/12/2024 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 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 and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 residents (Resident #78 and Resident #777) of 8 residents reviewed for infection control. Residents Affected - Few -Mediation Aide A failed to sanitize blood pressure equipment after taking Resident #777's blood pressure. Medication Aide proceeded to take Resident #78's blood pressure. This failure placed the residents at risk for cross contamination, infections, and a decrease in quality of life. Findings: Resident #777 Resident #777 was a [AGE] year-old male admitted to the NF on 11/30/34. Resident #777's diagnoses included the following: hypotension (low blood pressure), dementia (memory loss and judgement), Alzheimer's disease (progressive disease that destroys memory and other mental functions), and hypertension (high blood pressure). Resident #78 Record review of Resident #78's face sheet dated 12/12/24 revealed a [AGE] year-old male admitted to the NF on 10/22/24 with diagnoses that included the following: fatigue, dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when stomach acid or bile {fluid produced by the liver and stored in the gallbladder that helps with digestion} that irritates the food pipe lining, respiratory failure, and hypertension (high blood pressure). Observation on 12/10/24 during medication pass at 9:15AM of Medication Aide A taking Resident #777's blood pressure that was 122/79 and heart rate was 63. After taking Resident #777's B/P, Medication Aide A took the B/P equipment back to her medication cart without sanitizing the equipment. Observation on 12/10/24 at 9:23AM Medication Aide A went to Resident #78's room and took his B/P with the same B/P equipment with a blood pressure reading of 178/86 and heart rate of 63. When done, Medication Aide A took the B/P equipment back to her medication cart without sanitizing the equipment. In an interview on 12/10/24 at 9:40AM Medication Aide A said she was supposed to sanitize resident care equipment after each use to prevent cross contamination and infection control. Medication Aide A said she forgot to sanitize the blood pressure equipment. In an interview on 12/10/24 at 1:50PM the DON said the staff were supposed to sanitize all resident care equipment to prevent cross contamination and infections. Record review of the NF policy on Infection Control Prevention & Control Program revised 12/2023 revealed in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 10 of 13 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 12/12/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm .The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program .Reporting mechanisms for infection control .Effective and disinfecting equipment . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 11 of 13 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 12/12/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed: Residents Affected - Few - A roach was observed on a wall in the kitchen where food was being prepared for residents. These failures could place residents at risk for infections. The findings included: In an observation on 12/10/2024 at 11:39 AM, while [NAME] B was preparing soft mechanical food a semi-large roach crossed the wall in front of her and went behind a food mixer on the counter less than an arm's reach away. In an interview on 12/10/2024 at 11:39 AM, [NAME] B stated that she seen the roach on the wall while preparing food. She stated that she had seen roaches in the kitchen, but not a lot. She stated she last saw a roach about 1.5 months ago. She stated that when she saw pests in the kitchen, she informed the DM who informed maintenance. In an interview on 12/10/2024 at 11:41 AM, the DM stated that she had seen the roach on the wall while [NAME] B was preparing food. She stated that pest control services the kitchen every 2-weeks. She stated that the facility just switched to a new pest control company because the previous company's services were not working. In an interview on 12/10/2024 at 12:25 PM, DM, stated that she kept her kitchen clean, and maintenance was informed of the pest sighting in the kitchen. She stated that importance of reporting pests to maintenance was to keep the kitchen free of rodents and maintain infection control. In an interview on 12/12/2024 at 02:14 PM with the OM he stated they just switched pest control companies and the new company just serviced the kitchen on 12/11/2024. He stated when they learned of a roach siting on 12/10/2024, the FMD called the pest control company, and they came out. He stated there have not been any further pests siting since 12/10/2024 in the kitchen. He stated that all facility staff know to contact the Facility Maintenance Director (FMD) and report pest control issues to him immediately. He stated that residents' health and safety could be impacted if they failed to address pest control issues. In an interview on 12/12/2024 at 02:21 PM, the FMD stated that he had been with the facility for 18-years. He stated that they have a new pest control company servicing their pest needs. He stated that the previous company only laid pest compound on the outside of the facility. He stated the previous pest company told them their chemicals were not safe for indoor use and could harm the residents if they came into contact. He stated he had received reports of roaches, spiders, and tiny sugar ants and knew the company's product was not working. He stated as a result, they switched back to their original company about a month ago and they had not had any pest sightings since. He stated that clinical staff reported pests' issues to him directly or by adding it to a maintenance logbook kept at the nurse's station. He stated he checked the book twice a day, once in the morning and once in the evening. He stated the non-clinical, housekeeping staff sometimes reported issues to him through the facility communication app, whenever they seen any pests in the rooms. He stated whenever sightings were reported, he called the pest company to come out and spray immediately. He stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 12 of 13 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 12/12/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility also had an in-house pest chemical they used to spray. He stated the issues began when residents admitted with their own personal mini refrigerators. He stated that refrigerators are roach magnets. He stated that he had made it procedure that when new admissions admitted with refrigerators, they were to be placed out back for his inspection prior to being placed in the room. He stated that the admission team were aware of the procedure and were in full compliance. He stated he conducted an in-service on pest control at the facility's last all staff meeting, which he could not recall the date or time. He stated not addressing pest issues would be unsafe for the resident's health, and residents would not want pests near them. In an interview on 12/12/2024 at 03:26 PM, LVN H stated she works the 1st shift at the facility since May of 2024. She stated that she had not become aware of any pest control issues in the facility and had she, she would immediately report to FMD. She stated that the facility provided an in-service on pest control about a month ago. In an interview on 12/12/2024 at 03:32 PM, CNA R stated she works full-time, PRN for the facility. She stated that she had seen some roaches in the employee breakroom about 4-weeks ago and immediately reported the issue to the FMD. She stated that she received an in-service 2-weeks ago on pest control. Record review of pest service report dated 11/19/2024 and 12/05/2024, revealed that the facility was serviced for pest control in the interior and exterior areas and finding zero pest activity. Record review of facility in-service dated 12/10/2024 at 01:00 PM, with the dietary department revealed Report all rodent issues to manager, if manager not available report to assistant. Manager will report to maintenance. Recommendations/follow-up: maintenance were notified. Conducted by the DM. Record review of undated facility policy titled: Pest Control Policy/Procedure revealed: Subject: Pest Control. Policy: It is the policy of this facility provide an environment free of pests. Procedures: 1. The facility will have a pest control vendor contract that provides treatment of the environment for pests. 2. The pest control visits will occur at least monthly. 3. It will allow for additional visits when a problem is detected. 4. Monitoring of the environment will be done by the facility's state. 5. Pest control problems will be reported prompt. Tag: S/S= Surveyor Name(s): Immediate Supervisor: FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676194 If continuation sheet Page 13 of 13