Health inspection·December 1, 2022

F 0640 7/26/2022 .Stop billing. Level of Harm - Minimal harm or potential for actual harm Interview with LVN MDS H on 11/30/22 at 2:12pm, she said that she did not know why CR #1's discharge assessment had not been exported. When asked what the message Export Ready under CR #1's discharge MDS heading meant, she said it meant that the MDS had not been exported or transmitted to CMS and she did not know why since CR #1 discharged back in July of 2022. LVN MDS H said that it should have been exported or transmitted by now. When asked why the Complete MDS and Lock By: Submit By dates were highlighted in red, she said that the red highlighted dates indicated that the dates were late. When asked to clarify, she said that CR #1's discharge assessment had been completed late on 10/26/2022 and had been Locked By: Submit By, late on 11/04/2022. LVN MDS H said that LVN MDS T was the one who worked on CR #1's discharge assessment. She said the Regional RAI was the oversight person for her department that audited and checked to ensure the assessments were exported and transmitted; said the Regional RAI was oversight for a lot of other facilities. She said the MDS department had a director, but she left about 2 weeks ago. LVN MDS H said she was usure if there was a policy or procedure for exporting or transmitting MDS'. Residents Affected - Few Interview with LVN MDS T on 11/30/22 at 3:08 pm she said she did not know how she missed exporting or transmitting CR #1's discharge MDS. She said that it was possible that somehow the assessment got mistakenly checked as do not submit to CMS, instead of submit to CMS. She said that the assessment had been completed late and that it had been locked and submitted late, but she did not know why. She said that she did not know if the Regional RAI completed any audits of her department and apologized for CR #1's discharge not being completed, locked, or exported on time. She said it was an oversight. In a telephone interview on 12/1/22 at 2:13 pm with Regional RAI, she said she would be the regional oversight for the facility's MDS department and that she generally completed audits of the facility MDS' once per year. She said that an audit would usually consist of a record review of a random MDS sample of resident charts and care plans. She said that she would check each individual section of the MDS for accuracy and comparing the documentation in the look back period. She said the transmission, submission and exporting of MDS' would be the responsibility of the facility to monitor and ensure it was being completed and completed on time. The Regional RAI said she was not aware of any MDS issues or concerns at the facility regarding accuracy of assessments, exportation or submission of assessments and could not recall when she had completed her last audit at the facility. Record review of the facility's policy procedure titled MDS Completion and Submission Timeframes, dated as revised July 2017 read in part: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 2. Timeframe for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Record review of the CMS's RAI manual version 3.0 dated October 2019 revealed the following: Discharge assessment .MDS Completion Date .No Later Than .discharge date +14 Calendar Days. Transmission Date No Later Than .MDS Completion Date +14 Calendar Days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676236 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 676236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately assess each resident's status for 1 of 48 Residents (Resident #8) reviewed for assessment accuracy in that: Residents Affected - Few - Resident #8's 5-day MDS dated [DATE] incorrectly coded his use of anticoagulant medication. This failure could place residents at risk of not receiving the proper care and services due to inaccurate medication coding, and records. Finding include: Record review of Resident #8's admission record revealed he was an [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (condition affecting the blood flow to the brain that results in changes in memory, thinking and behavior), essential hypertension (high blood pressure not caused by secondary causes or medical conditions), hyperlipidemia (high cholesterol), and retention of urine (difficulty urinating and completely emptying the bladder). Record review of Resident #8's 5-day MDS dated [DATE] revealed he had a BIMS score of 8 indicating that he suffered from moderately impaired cognitive skills for decision making. Resident #8 was coded in section N of the 5-day MDS for medication, as having received 5 days of an anticoagulant (a medication that had the effect of inhibiting the coagulation of blood). Record review of Resident #8's EMR orders revealed Resident #8 had an order dated * for the medication Clopidogrel (Plavix) which was an antiplatelet medication used to reduce the risk of heart disease and stroke. Interview with LVN MDS H on 11/29/22 at 1:21 pm, she said she had completed the 5-day MDS dated [DATE] for Resident #8 and had mistakenly coded his Plavix/Clopidogrel as an anticoagulant and probably should not have because it was an antiplatelet medication. She said she made an error and could modify the MDS to correct it. She said that she used and followed the CMS RAI manual as her guidance and as the policy and procedure she followed. Telephone interview on 12/1/22 at 2:13 pm with Regional RAI who said that she would be the regional oversight for the facility MDS department and that she generally completed audits of the facility MDS' once per year. She said that an audit would usually consist of a record review of a random MDS sample of resident charts and care plans. She said that she would check each individual section of the MDS for accuracy and comparing the documentation in the look back period. She said the transmission, submission and exporting of MDS' would be the responsibility of the facility to monitor and ensure it was being completed and completed on time. The Regional RAI said she was not aware of any MDS issues or concerns at the facility regarding accuracy of assessments, exportation or submission of assessments and could not recall when she had completed her last audit at the facility. Record review of the CMS' RAI Manual 3.0 dated October 2019 revealed the following entry: N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676236 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 676236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070 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 0641 Level of Harm - Minimal harm or potential for actual harm clopidogrel here. received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676236 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 676236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASRR for 1 of 12 residents (Resident # 100) reviewed for PASRR. Residents Affected - Few The facility failed to correctly code Resident #100's PASRR Level I assessment for mental illness. This failure could place residents with mental illness at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings include: Record review of Resident #100's admission record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: major depressive disorder, single episode (mental health condition of persistently depressed moods), post-traumatic stress disorder (a disorder in which a person had difficulty recovering after experiencing or witnessing a terrifying event). Record review of Resident #100's PASRR Level I Screening dated 09/19/2022, revealed no evidence or indication that he had a mental illness. Record review of Resident #100's care plan, dated 09/23/2022, revealed the following: Focus: Resident #100 had ineffective coping due to post traumatic stress disorder. Goal: Encourage resident to meet other people with similar interest and participate in group programs. Resident will verbalize feeling safe and a reduction in disturbances (anxiety, flashbacks, depression, nightmares); Interventions: Resident #100 referral to [company name] psychiatric services. Record review of Resident #100's admission MDS assessment, dated 09/26/2022, revealed he was able to make himself-understood and was able to understand others. The resident had a Brief Interview for Mental Status score of 15 out of 15 which indicated his cognition was intact. His active diagnoses included Depression (other than bipolar) and post-traumatic stress disorder. Resident #100 received anti-depressant medication. Record review of Resident #100's care plan, dated 12/01/2022, revealed: Focus: Resident #100 used antidepressant medications (Trazodone) related to depression; Goal: Resident #100 will show decreased episodes of signs/ symptoms of depression; Interventions: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Record review of Resident #100's physician's order, dated 12/01/2022, revealed an order Trazodone 50Mg. Give two tablets at bedtime for sleep related to major depressive disorder, single episodes. Order dated 11/01/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676236 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 676236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 12/01/2022 at 8:45AM, LVN MDS T stated the purpose of the PASRR was to determine if a resident was positive for mental illness, intellectual disabilities or developmental disabilities and would qualify for specialized services. The risk of an incorrect PASRR screening was the resident would not receive the specialized services they were entitled. The MDS nurse was responsible for the PASRR accuracy. She stated a Major depressive disorder and post-traumatic stress disorder were diagnoses that would be result in a positive PASRR level 1. Resident #100 was not coded correctly due to his major depressive disorder and post-traumatic stress disorder. She stated to prevent this from occurring again we need to pay more attention the resident's diagnosis and review it in our morning meeting. In an interview on 12/01/2020 at 9:50 AM the DON stated the PASRR was to help identify special services a resident maybe entitled. An incorrectly coded PASRR could prevent a resident from specialized services that could benefit their health and quality of life. Resident #100 had major depressive disorder and post-traumatic stress disorder. He was not coded correctly on his PASRR. The DON stated we would review all diagnosis to make sure the PASRR was coded correctly. In an interview on 12/01/2022 at 10:15 AM the Administrator stated the Risk of an incorrectly coded PASRR was the resident may not get additional community services and support to help provide for his care and quality of life. Resident #100 did have diagnoses of major depressive disorder and Post-Traumatic Stress Disorder for a positive PASRR. He was not coded correctly and they would review resident diagnosis to make sure PASRR's were coded correctly. Record review of the facility's policy titled readmission Screening and Resident Review Reports (PASRR) last revised dated 09/2017 read in part .The purpose of the Preadmission Screening and Resident Review Reports (PASRR) is to verify that the resident meets the criteria for skilled nursing home placement where required, and as per stated regulations. Policy Detail: A. An initial Preadmission Screening and Resident Review (PASRR) shall be completed prior to or upon admission of all residents with mental illness (MI) or mental retardation (MR) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676236 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 676236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070 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 - Many 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 ensure that food was stored and served in accordance with professional standards for review for food service safety in one of one kitchens used by the facility, in that: - Hot foods were not held at 135F and above and cold foods were not held at 41F and below. - Pureed foods were not reheated to desired temperature of at least 135F prior to serving the meal. These failures can affect all resident who consume food served by the facility and place them at risk for acquiring a food borne illness. Findings included: Record review of the lunch menu, dated 11/30/2022 included, chicken tenders, pasta salad and steamed chef's vegetables Observations of the kitchen on 11/30/2022 from 11:38AM through 11:50AM, [NAME] A pureed cooked chicken in blender for 10 minutes. Surveyor tasted the finished pureed chicken and it tasted room-temperature. [NAME] A put the pureed chicken in a small pan and passed it to Dietary Aide B without reheating it. The steam table was observed to be full of other food items. Dietary Aide B placed the pureed chicken on the counter beside the steamtable. Another food item on the line that were observed sitting outside of the steamtable included chicken tenders. Observations of the kitchen on 11/30/2022 at 11:50AM through 12:16 PM, revealed [NAME] A pureed cooked blended vegetables, placed it in a pan, did not reheat it, and passed it to Dietary Aide B who placed it in the steam table. Macaroni salad was blended by [NAME] A, put in a pan, handed to Dietary Aide B who placed it on the counter without putting it on ice. Dietary Aide B plated the pureed foods on a plate and warmed it in the microwave for 16 seconds prior to having meal placed on the food cart for meal service. During observations of the food line during meal service on 11/30/2022 at 12:20PM, temperatures of the pureed foods were taken by surveyor using facility thermometer with Food Service Director present. Test tray containing pureed chicken, pureed blended vegetables and pureed macaroni salad revealed food temperatures were 103F, 105F and 93F, respectively. [NAME] A temped the chicken tenders that were sitting outside of the steam table at 87F. Dietary Aide B stated she microwaved the plate of pureed food for 16 second prior to putting on the cart for meal service because [NAME] A handed her the food items straight from the blender, so they were cold. In an interview on 11/30/2022 at 12:21PM with Food Service Director, Executive Chef and Dietary Aide B, Food Service Director stated he normally never seen hot foods sitting outside of the steam table like that, the food was supposed to be sitting in the steam table. Executive Chef stated the food was cold due to the AC vents blowing directly on the uncovered food and some foods are sitting outside the steamtable when they were supposed to be in the steamtable. Dietary Aide B stated this was not the first time foods have sat outside of the steamtable. Dietary Aide B stated it would be helpful to have the chefs condense the foods in the right size pans and set up the steamtable so we could learn from them how it should be set up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676236 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 676236 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070 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 - Many In an interview on 12/01/2022 at 10:45AM, Food Service Director stated at time food was being served, hot foods are to be 140F and above while in the steamtable and cold food are to be 41F and below while on ice. He said, however, it was technically okay for the pureed macaroni salad to be above the temperature of 41F as long as it is eaten within 4 hours of meal service. He said any food that was eaten outside of the 4-hour time range was hazardous. He said the mistakes were made yesterday likely due to kitchen staff being nervous. The policies on hot holding and cold holding foods were requested at this time but were not provided prior to exit. Record review of the food temperature log, dated 11/30/2022, revealed that the macaroni salad was temped at 61F prior to meal service. Record review of the FDA Food Code, dated 2017, revealed foods are to be kept at 41F or less for cold holding and kept at 135F or greater for hot holding to prevent growth of pathogens and prevention of foodborne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676236 If continuation sheet Page 8 of 8