Health inspection·March 7, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm During an observation and interview on 03/05/24 at 1:05 p.m., CNA K said Resident #2's call light was tied at the head of the bed and fell to the floor behind the head of the bed. CNA K said she was not the resident aide. CNA K said Resident #'s2 call light should be within reach when the resident was in the room or bed for Resident #2 to call for assistance, and Resident #2 could fall if she tried to reach for the call light and lost her balance. CNA K said she had a skills check-off, which included call light positioning. Residents Affected - Few During an interview on 03/05/24 at 1:17 p.m., CNA T said she did not notice the call light for Resident #2 was on the floor behind the head of the bed. CNA T said Resident #2's call light should be within reach. If Resident #2 falls, she could call for assistance or ask if Resident #2 needed help for any other care. CNA T said she had in-service on-call light placement. CNA T said the nurses are responsible for monitoring the aides to ensure they are providing care for the residents. During an interview on 03/05/24 at 4:10 p.m., the DON said Resident #2 call light should be within reach of Resident #2 so she could use the call light to call for assistance. The DON said the resident may only get assistance promptly if the call light was within reach of Resident #2. The DON did not respond when Surveyor N asked what could happen to Resident #2 if care was not provided to the resident on time because the call light was not within reach and Resident #2 could not call for help. Record review of Resident #3's face sheet dated 03/05/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Resident #3 had diagnoses which included: cerebral infraction (disrupted blood flow to the brain), diabetes mellitus (elevated levels of blood glucose), and hypertension (a condition which the blood vessels have persistently raised pressure) Record review of Resident #3's quarterly MDS assessment, dated 01/05/24 revealed: Resident #3 revealed BIMS of 03 indicated severely impaired cognation Resident #3's functional status revealed he required limited to extensive assistance with bed mobility, transfer, and toilet use. Further review revealed Resident #3 had one fall. Record review of Resident 3's care plan initiated 04/04/23 revealed the resident was at risk of fall related to impaired mobility, poor cognition. Intervention: be sure Resident#3's call light was within reach and encourage Resident #3 to use it for assistance as needed. During an observation and interview on 03/05/24 at 12:45 a.m., it was revealed that Resident #3's call light was tied to the head of the bed, out of reach for the resident. When Surveyor N asked Resident #3 if she could reach the call light, Resident #3 did not respond. During an interview on 03/05/24 at 1:07 p.m., CNA K said Resident #3's call light was hanging on the head of the bed. The call light was not within reach, and Resident #3 could not reach it. CNA K said the call light should always be within reach. During an interview on 03/05/24 at 1:19 p.m., CNA T said she was the CNA for Resident #3 and she had made rounds since she came to work today, and was not the aide who tied the call light on the head of the bed for Resident #3. During an observation and interview on 03/05/24 at 2:28 p.m., LVN F said Resident #3's call light was attached to the head of the bed, and Resident #3 could not use the call light. LVN F said Resident #3 call light should be within so she could call for assistance. LVN F said Resident #3 could fall if Resident #3 tried to reach for the call light. LVN F also said Resident #3 could not get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 2 of 8 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 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance on time when Resident #3 could not reach the call light, and it could delay care, which could have a critical outcome for Resident #3. LVN F said he did not remember any training about call lights, but he had general training. LVN F said he would be the person to monitor the aides, and the nurse managers monitor him when they make random rounds. During an interview on 01/07/24 at 4:36 p.m., the administrator said the call light should be within reach for all residents, and sometimes the resident throws the call light on the floor. When the administrator was asked what could happen if a resident needed assistance and could not reach the call light, The administrator did not respond but said the staff would place the call light within reach of the resident when the staff saw it was not within reach. Record review of undated facility policy on call light accessibility and timely response read in part . policy explanation and compliance guidelines #5 . staff will ensure the call light is within reach of the resident, and secured as needed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 3 of 8 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 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 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 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1of 5 residents (Resident #4) reviewed for ADLs. Residents Affected - Few 1. The facility failed to ensure Resident #4 was provided personal grooming (fingernail care) by facility staff. This failure could place residents at risk for discomfort, and dignity issues. Findings included: 1. Record review of Resident #4's face sheet dated 03/05/24 revealed a [AGE] year-old female admitted to the facility on 1. 01/01/24. Resident #4 had diagnoses which included: dementia (loss of thinking, remembering, and reasoning, which may interferes with a person's daily life and activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness), and hypertension (a condition which the blood vessels have persistently raised pressure) Record review of Resident #4's MDS assessment, dated 03/01/24 revealed: Resident #4's MDS was not done because Resident #4 was a new admit and she was admitted on [DATE]. Record review of Resident 4's care plan initiated 03/05/24 revealed the resident had an ADL self - care performance related to limited mobility and weakness. Intervention: The resident requires minimal to moderate assistance by 1-2 staff with personal hygiene. Further review revealed Resident #4 refuses fingernails to be clipped. During an observation and interview on 03/05/24 at 1:47 p.m., Resident #4's fingernails were two inches long on both hands. Resident #4 said CNA K showered her today, but she did not cut her fingernails, and she wanted her fingernails cut. Resident #4 said she had not refused the aides from cutting her fingernails. During an observation and interview on 03/05/24 at 1:49 p.m., CNA K said she was Resident #4's aide today and gave Resident #4 a shower. CNA K said she saw Resident #4's long fingernails on both hands very long but did not ask Resident #4 if she wanted her fingernails cut. CNA K SAID Resident #4 had not refused to cut her fingernails or refused to shower. CNA K said Resident #4 could scratch herself, and dirt could collect under Resident #4's fingernails. CNA K said she had a skills check-off, which included nail care. CNA K said residents' nails are cut on shower days and as needed. CNA K did not respond when asked why she did not offer to cut Resident #4's fingernails. CNA K said the charge nurse monitored the aides when they made rounds. During an interview on 03/05/24 at 4:13 p.m., the DON said CNA K should offer to cut Resident #4 fingernails during the shower and as needed. The DON said Resident #4 could scratch herself, and dirt could accumulate under the nails. The DON said he just texted the wound care nurse to go and cut Resident #4's fingernails, and she refused. The DON said he would care plan Resident #4's refusal to cut her fingernail. The DON said the nurse monitors the aides when she makes rounds and makes sure the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 4 of 8 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 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 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 aides are providing care for the residents. Surveyor N asked the DON if there was any documentation of Resident #4 refusing fingernail care before today (03/05/24), and he did not respond. During an interview on 03/07/24 at 4:42 p.m., the Administrator said the DON said Resident #4 refused to cut her fingernails, which was care planned. Then the Administrator said wait, and I would go and get the shower sheets. During an interview on 01/07/24 at 4:45 p.m., the Administrator returned and said the DON said there would be no need to look at Resident #4's shower sheets because he had care planned; Resident #4 refused care. Record review of the facility policy on nail care dated Copyright 2023 The Compliance Store, LLC. All rights reserved read in part . The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 5 of 8 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 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 residents (Resident #1, and Resident #3) reviewed for incontinent care. 1. The facility failed to ensure Resident #1's foley tubing was not touching the floor while Resident #1 was propelling himself between the nursing station and medication room. 2. The facility failed to ensure Resident # 3's foley bag and tubing were not touching the floor while Resident #2 was laid in bed. This failure could place residents at risk for pain, infection, injury, and hospitalization. Findings included: 1. Record review of Resident #1's face sheet dated 03/05/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses which included: dementia (loss of thinking, remembering, and reasoning, which may interfere with a person's daily life and activities), benign prostatic hyperplasia (condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and hypertension (a condition which the blood vessels have persistently raised pressure). Record review of Resident #1's quarterly MDS assessment, dated 02/08/24 revealed: Resident #1 revealed BIMS of 03 indicated severely impaired cognation Resident #1's functional status revealed he required limited to extensive assistance with bed mobility, transfer, and toilet use. Further review revealed Resident#1 had an indwelling catheter. Record review of Resident 1's care plan initiated 10/12/23 read in . the resident had indwelling catheter related difficulty in passing urine. Intervention: Catheter care every shift and PRN (as needed) and check tubing for kinks during each shift. Record review of Resident #1's March 2024 order summary report read in part .foley 6 - FR - 10 cc bulb every month or as needed for neuromuscular dysfunction of bladder. Order date: 02/15/24 . During an observation on 03/05/24 at 11:00 a.m., Resident #1 was seated in his wheelchair by the nursing station close to the medication room. As Resident #1 propelled himself, the foley tubing dragged on the floor. During an observation and interview on 03/05/24 at 11:02 a.m., LVN B said Resident #1's foley tubing was touching the floor as Resident #1 moved his wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 6 of 8 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 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/05/24 at 11:38 a.m., Resident #1 could not say if he saw his Foley tubing touching the floor or if he had transferred himself from the bed to the wheelchair. During an interview on 03/05/24 at 11:40 a.m., CNA A said she did not remember seeing Resident #1's foley tubing touching the floor, and the tubing should not be touching the floor to prevent infection. CNA A said she did not get Resident #1 up in the morning because the night shift got him up, but she had seen Resident #1 a couple of times this morning but did not notice the foley tubing dragged on the floor as he propelled his wheelchair. CNA A said she had in-service training on working with residents who had Foley, and the charge nurse monitors the aides to ensure they provide care the correct way for the residents. During an interview on 03/05/24 at 3:07 p.m., LVN B said Resident #1's foley tubing was touching the floor as he propelled himself. LVN B said the foley tubing should not touch the floor because of infection. LVN B said the foley could leak urine on the floor, and other residents could get contaminated with any organism in Resident #1's urine. LVN B said Resident #1 could get UTI (urinary tract infection) from any microorganisms from the tube, which was picked up when Resident#1 was dragged the tubing on the floor if the germ traveled to the resident's bladder. LVN B said she had skills - check off on working with a resident with foley. LVN B said the nurse was responsible for ensuring Resident#1's foley tubing was not touching the floor. During an interview on 03/05/24 at 4:03 p.m., the DON said Resident #1's foley tubing should not be touching the floor because of infection control, which meant the urine could spill on the floor because it was a biological substance. The DON said it had to be cleaned and disinfected. The DON said the ADON, and the nurse managers monitor nurses when they make random rounds to ensure the residents receive appropriate care. The DON said he was unaware that Resident #1's foley tubing was touching the floor. 2. Record review of Resident #3's face sheet dated 03/05/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. Resident #3 had diagnoses which included: cerebral infraction (disrupted blood flow to the brain), diabetes mellitus (elevated levels of blood glucose), and hypertension (a condition which the blood vessels have persistently raised pressure) Record review of Resident #3's quarterly MDS assessment, dated 01/05/24 revealed: Resident #3 had a BIMS of 03 indicated severely impaired cognation. Resident #3's functional status revealed he required limited to extensive assistance with bed mobility, transfer, and toilet use. Further review revealed Resident #3 had a foley. Record review of Resident 3's care plan initiated 04/04/23 revealed the resident had indwelling catheter related to pressure ulcer to sacral area. Intervention: change foley catheter PRN (as needed) patency for sacral wound please document 16 FR/BULB 10 cc and check tubing for kinks during each shift. Record review of Resident #3's March 2024 order summary report read change foley catheter for patency as needed for sacral wound. Observation on 03/05/24 at 12:47 a.m. revealed Resident#3's foley bag and tubing were lying on the floor towards the foot of the bed. During an interview on 03/05/24 at 12:51 p.m., LVN F said Resident #3's foley bag and tubing were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 7 of 8 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 676221 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some touching the floor by the foot of the bed. LVN F said the Foley bag and tubing were not supposed to touch the floor because it could stop the urine from draining, and it could be an infection control issue because Resident #3 could get UTI if the germs traveled to Resident #3 urethra. LVN F said he came to work at 6:00 a.m. and did not notice Resident #3 Foley's bag touching the floor when he made rounds, and his last round was at 11:45 a.m. LVN F said he would be the person who monitors the aides to make sure they provide appropriate care for residents with Foley, and the nurse managers monitor the nurses when they make rounds. LVN F said he had no training or skills check on Foley care. During an interview on 03/05/24 at 1:21 p.m., CNA T said Resident #3's foley bag and tubing should not touch the floor because it was cross-contamination, and Resident #3 could get infected. CNA T said she did not notice Resident #3's Foley bag and tubing were touching the floor when she came in at 6:09 a.m. and when she made rounds. CNA T said the foley bag and tubing were touching the floor because Resident #3's bed was in a low position, but if she had raised the bed a little, it could have prevented the foley from touching the floor. She said she had skills check-off and in-service training on how to work with a resident who had a Foley. CNA T said the charge nurse monitors the aide when she makes rounds to ensure the aides are providing care for the residents. During an interview on 03/05/24 at 4:06 p.m., the DON said the foley bag and tubing should not be touching the floor because of infection control. Record review of the facility registered and licensed nurse competency which included urinary catheterization and it revealed LVN B signed off on it on 03/01/24. Record review of the facility registered and licensed nurse competency which included urinary catheterization and it revealed LVN F signed off on it on 03/01/24. Record review of the facility nurse aide competency revealed, which included drain/tube management and it revealed CNA T signed off on 03/01/24. Record review of the facility policy on catheterization dated Copyright 2023 The Compliance Store, LLC. All rights reserved read in part . urinary catheterization .standards of practice to minimize risk for bacterial contamination . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676221 If continuation sheet Page 8 of 8