Health inspection·December 1, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #34's admission record dated 11/29/203 revealed an [AGE] year-old resident admitted on [DATE]. Her diagnoses included muscle weakness, lack of coordination, dementia (group of symptoms that affects memory, thinking and interferes with daily life), right leg amputation above the knee, wheelchair dependence, and Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Residents Affected - Some Record review of Resident #34's admission MDS dated [DATE] with an ARD of 11/6/2023 revealed a BIMS score of 10 indicating a moderate cognitive impairment. The MDS documented she required a wheelchair for mobility. Per the MDS, Resident #34 required partial to substantial assistance with hygiene, bathing, dressing, and transfers. The MDS revealed Resident #34 did not walk during the review period. The MDS documented she received occupational therapy. Record review of Resident #34's undated care plan revealed a focus on her fall risk with interventions including ensuring her call light was within reach and encouragement to use the call light. Observation on 11/28/2023 at 8:54 AM of Resident #34 revealed she was sitting on the edge of her bed. Resident #34's call light was on the floor by her bed in a position she could not reach. An interview was not conducted due to her cognitive abilities. Resident #43 Record review of Resident #43's admission record dated 11/28/2023 revealed an [AGE] year-old resident admitted on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (group of symptoms that affects memory, thinking and interferes with daily life), difficulty in walking, lack of coordination, and repeated falls. Record review of Resident #43's significant change MDS dated [DATE] with an ARD of 10/12/2023 revealed a BIMS score of 7 indicating a significant cognitive impairment. The MDS documented she utilized both a walker and wheelchair for mobility. Per the MDS, Resident #43 required partial to substantial assistance with hygiene, toileting, showering, dressing, transfers, and walking. The MDS revealed she did not receive any rehabilitative therapeutic services. Record review of Resident #43's undated care plan revealed fall risk with interventions including ensuring her call light was within reach and she was encouraged to use it. Observation on 11/28/2023 at 8:51 AM of Resident #43 revealed she was sitting in her bed with the head up eating her meal. Resident #43's call light was lying on the floor behind her bed in a position she could not reach. An interview was not conducted due to her cognitive abilities. Resident #51 Record review of Resident #51's admission record dated 11/29/2023 revealed an [AGE] year-old man admitted on [DATE]. His diagnoses included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), lack of coordination, muscle weakness, and difficulty walking. Record review of Resident #51's quarterly MDS dated [DATE] with an ARD of 10/5/2023 revealed no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 2 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 BIMS was completed because he was rarely or never understood. The MDS documented he had short and long-term memory problems, and he was moderately impaired in his cognitive skills for daily decision making. Per the MDS, Resident #51 did not utilize any mobility devices. The MDS revealed he required supervision or touching assistance with eating, dressing, hygiene, toileting, dressing, showering, transfers, and walking. The MDS documented he did not receive any rehabilitative therapeutic services. Residents Affected - Some Record review of Resident #51's care plan dated 10/6/2023 revealed a focus on his fall risk with interventions including ensuring his call light was within reach and encouraging him to use it. Observation on 11/28/2023 at 9:00 AM of Resident #51 revealed he was sitting in a recliner style chair. Resident #51 appeared clean and appropriately dressed. Observation on 11/29/2023 at 8:37 AM of Resident #51 revealed he was lying on his bed. Resident #51's call light was lying on the floor under his bed in a position he could not reach. An interview was not conducted due to his cognitive abilities. Resident #70 Record review of Resident #70's admission record dated 11/29/2023 revealed an [AGE] year-old woman admitted on [DATE]. Her diagnoses included muscle weakness, difficulty walking, dementia (group of symptoms that affects memory, thinking and interferes with daily life), cataract (cloudy area in the eye lens), and lack of coordination. Record review of Resident #70's admission MDS dated [DATE] with an ARD of 9/15/2023 revealed a BIMS score of 7 indicating a moderate cognitive impairment. The MDS documented she required one or more person assistance with bed mobility, transfers, walking, locomotion, dressing, eating, toileting, and personal hygiene. Per the MDS, Resident #70 utilized a wheelchair for mobility. The MDS revealed she received both OT and PT services. Record review of Resident #70's care plan dated 9/16/2023 revealed a focus on her fall risk with interventions including ensuring her call light was within reach and she was encouraged to use it. Observation on 11/28/2023 at 9:06 AM of resident #70 revealed her call light was behind her bed in a position she could not reach. Resident #70 was sitting on her bed. An interview was not conducted due to her cognitive abilities. Interview on 11/28/2023 at 9:07 AM with CNA TTT said the facility expected all residents' call lights to be within reach. CNA TTT said Resident #70's call light was not within reach . CNA TTT said if a resident could not reach his/her call light, the resident could fall trying to get out of bed or reaching for the light. CNA TTT said the facility policy was that all residents' call lights should be in a position the resident was able to reach. Interview on 11/29/2023 at 8:54 AM with the Admin, he said his expectations for call lights at the facility was that call lights should be answered by all team members including department heads. The admin said if the resident needed ADL assistance, he expected non-nursing staff to get nursing staff to complete the required tasks for the residents. The Admin said he expected call lights to be within reach of the residents. The admin said if call lights were not within reach of the residents, the residents could fall out of bed reaching for it, or if the resident needed something he/she could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 3 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 - Some not call staff for assistance. The Admin said he thought the call lights might be behind and under beds after housekeeping cleaned the room. The admin said he would ensure housekeeping do not leave the call lights behind beds. The admin said the staff conduct Angel Rounds and the placement of the call lights should be reviewed during the angel rounds. Interview on 12/1/2023 at 10:07 AM with the DON, she said she expects residents' call lights to be within reach of the residents and answered as soon as possible. The DON said the call lights should be within reach, so the residents were able to ask for assistance. The DON said if the call lights were not within reach, residents would not be able to ask for assistance and would not have their needs met. The DON said call lights should be answered as soon as possible so the residents do not have to wait for the care they need. Record review of an email from the administrator dated 11/30/2023 at 12:31 PM read in part .[the facility] does not have a Call Light Policy . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 4 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 6 of 6 confidential residents reviewed for weekend mail delivery. Residents Affected - Many The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life. Findings include: A confidential group interview was conducted on 11/29/2023 at 10:04 AM with six residents and one resident's family member who translated for the resident. All six residents denied receiving mail on Saturdays. A resident said the facility received mail on Saturdays, but it was stored in the office and given to residents on Monday mornings. Interview on 11/30/2023 at 1:12 PM with the AD, she said she had been employed for three years. The AD said her primary duties included implementation and development of activities for the residents based on the residents' needs, interests, and abilities. The AD said she was also responsible for mail delivery. The AD said she delivered the mail room to room when it was delivered to the facility. The AD said mail delivery was part of her in room visits with residents. The AD said her schedule was Monday to Friday from 6:00 AM to 3:00 PM. The AD said she delivered mail on her workdays. The AD said if mail was delivered to the facility for a resident on a Saturday, the nurse would collect the mail, place it in the office, and let the AD know it was present. The AD said she would then deliver that mail on the following Monday when she was at work. The AD said she was unsure if there was a mail delivery policy. The AD said she did not know of any issues which could arise if a resident did not receive his/her mail on a Saturday. Interview on 11/30/2023 at 4:05 PM with the Admin, he said the facility had not delivered mail to the residents on Saturdays. The Admin said he had never been informed by residents that Saturday mail delivery had been a concern. The Admin said he thought either the weekend charge nurse or another nurse had been delivering the mail. The Admin said the residents had never complained to him about the lack of mail service. The Admin said regulations required mail to be delivered on all days the facility received mail. The Admin said the facility was determining how to ensure mail was delivered on Saturdays going forward. Record review of the facility's Resident Mail Delivery and Distribution policy dated March 2011 revealed a policy statement which read The health care center will develop a system to deliver and distribute resident mail in accordance with privacy and confidentiality regulations. The policy required the activity department to appoint a staff member or volunteer to deliver the mail to the residents every day that the facility received mail or parcels. The policy documented the mail would be delivered unopened to the residents. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 5 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure allegations of abuse, neglect or mistreatment, including injuries of unknown origin was reported immediately, but not later than 2 hours after the allegation is made for 1 (Resident#28) out of 4 residents reviewed for reporting alleged abuse and neglect. -The facility failed to report Resident#28's fracture of lumber spine that was discovered on 11/08/2023 to the state agency. This failure could place residents at risk for not having incidents reported as required and continued abuse and neglect which could result in diminished quality of life. Findings include: Record review Resident#28 face sheet (undated) revealed she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included cognitive communication deficit (difficulty with thinking and how someone uses language), Parkinson disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) and type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar (glucose). Record review of Resident#28's Quarterly MDS assessment dated [DATE] revealed BIMS score of 11 out of 15 indicating moderately impaired cognitively. She was depended on staff for toileting hygiene, shower/bathing and lower body dressing, Record review of Resident#28's comprehensive care plan initiated on 09/15/2017 and revised on 9/17/23 revealed the following: Focus: The resident is risk for falls r/t Gait/balance problems. Goal: The resident will be free of falls through the review date. Target Date: 01/05/2024. Goal: The resident will not sustain serious injury through the review date. Target Date: 01/05/2024. Interventions: Resident with actual fall from bed states she was having hallucinations. Resident sent to hospital. DON/R/P and MD notified. Resident with actual fall states she had a bad dream and fell out of bed. States her right leg hurts 911 called. Resident returned from hospital no injuries noted. staff to continue to monitor. Resident with actual fall states she someone calling her name and tried to walk to find the person calling her. Resident with bruise and abrasion to ABD. DON/RP, MD and Administrator notified. Staff to ensure bilateral floor mats are in place when resident is in bed. Staff to remove mats when using hoyer lift for safety. Resident will put her bed in the highest level when she is in bed, staff to continue to remind resident she has fallen from the bed before and to try to keep the bed in the lowest position while she is in the bed. Record review of TULIP (Texas Unified Licensing Information Portal) on 11/28/23 and 12/01/23 revealed no reported alleged incidents of Abuse or Neglect, injury of unknown origin having to do with Resident#28. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 6 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0609 Level of Harm - Minimal harm or potential for actual harm Record review of Resident#28's Fall-Risk Assessment-V2 dated 10/31/2023 5:50am revealed resident was a high risk. Score: 14. Record review of Resident#28's Fall-Risk Assessment-V2 dated 11/11/2023 8:37pm revealed resident was a high risk. Score: 13. Residents Affected - Few Record review of Resident #28's progress note written by RN DDD on 10/31/2023 at 07:43am read in part: .CNA heard resident screaming from her room. Upon entering the room, resident was noted lying on her abdomen on the floor. She immediately came to get me. Upon my arrival, resident was lying on her abd. on the floor next to her bed c/o back and neck pain. Resident was assessed AAOX3 no skin tear. 911 was called for resident to be sent out for evaluation at the hospital . Record review of Resident#28's hospital discharge date d 10/31/23 revealed read in part: .You were seen today for: Fracture of lumber spine. Activity Restrictions or Additional Instruction: Follow-up closely with your doctor and also neurosurgery for the back fracture. HPI notes: [AGE] year old female history of multiple medical problems to the emergency department after an unwitnessed fall. Patient reports that she was lying in the bed whenever she had a fall out of the bed and landed on her bottom. She did not hit her head. However, she is having pain to the back of her head. Also having back pain and knee pain Record review of Resident #28's progress note written by LVN IIII on 11/4/23 at 2:01pm revealed read in part: .Resident noted yelling out help numerous times, upon my arrival, resident c/o back pain, says she thinks her back is broke, says she heard a crack when she turned on her side, res said she wants to call 911 and go to the hospital, this nurse told res that I need to call the doctor, res insisted on calling 911, I also offered to give resident a prn pain pill and resident refused, this nurse continued to offer prn to res, she finally agreed, and then said it's not going to work. This nurse called the On call line and left a message to have the doctor or NP on call return my call. Ambulance arrived at approximately 1245, this nurse gave them report, res was transported to the hospital at this time. Z on call for Dr returned my call, this nurse notified her of res transport to the hospital per res request and that she called 911 on her own. DON notified . Record review of hospital record dated 11/8/23 revealed read in part: .Patient completed bone scan and revealed acute compression fracture of L2. Surgical and nonsurgical options were discussed including kyphoplasty (Kyphoplasty way of treating vertebral body compression fractures, which are small breaks in the thick mass of bone that makes up the front part of your spinal column (the vertebral body) versus LSO brace. After reviewing risks and benefits including but not limited to bleeding, hematoma, extravasation of cement, nerve damage, need for further treatments, patient is agreeable to move forward with L2 kyphoplasty . Record review of Resident #28's progress note written by LVN KKKK on 11/11/23 at 11:48pm revealed read in part: .resident received back to facility via stretcher, Re-admit, stable no complaints of pain or discomfort at this time, medications review by NP, resident had s/p KYPHOPLASTY. small incision to mid back area, compression fracture lower back, vital signs stable. bed bound . Observation and interview on 11/28/2023 at 12:36p.m., with Resident#28 revealed her resting in bed receiving O2 via NC at 4L. She had multiple bruises on her neck and on the right hand and couple of dry dressing dated 11/28/23 on the left forearm. Fall mats on both sides of the bed. Bed was in high position. Resident said the devil told me to fall out of bed. I ended up breaking my back and had surgery. I laid on the floor for 15 minutes screaming for help. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 7 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/28/2023 at 1:06p.m., LVN FFFF said the Administrator was facility's abuse coordinator. She said any allegations of abuse and neglect were to be reported to the DON and Administrator immediately. She said Resident#28 had an unwitnessed fall and was sent the hospital and return with kyphoplasty Record review and interview on 11/28/23 at 2:02p.m., with the DON, Surveyor reviewed Resident #28's hospital records dated 10/31/23 and 11/4/23 with the DON. Interview with the DON who said Resident #28 fell on October 31, 2023, and was sent to the hospital. She said Resident returned the same day with compression fracture. She was scheduled for cervical epidural block appointment at the pain management office on 11/15/23. She said Resident did not make it to that appointment. She was sent back to the hospital few days later 11/4/23. Resident called 911 for pain. At that time, they did surgery for the L2 fracture from 10/31/23. Interview on 11/30/23 at 1:29p.m., with the Administrator, he said he was the abuse coordinator. He said Resident#28 lumber fracture was not reportable. He said it was not an significant injury, or suspicious injury. Resident had fallen on 10/28/23 and was rechecked on 10/31/23 at the hospital. Resident was able to tell how she fell. He said he followed the provider letter 19-17 (Replaces PL 17-18) and discussed with corporate, and it was decided that Resident was alert, knew how/what happened so it was not a suspicious injury, major injury. When asked what he considered to be significant injury the Administrator said, falls fractures with injury of unknown origin, hip fracture, fracture of the femur. Interview on 11/30/23 at 1:19p.m., with CNA SS, she said Resident#28 was a fall risk. She said Resident had several unwitnessed falls and recently had back surgery. Record review of Long-Term Care Regulatory Provider Letter Number: PL 19-17 (Replaces PL 17-18) revealed read in part: .Type of Incident-neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury. When to Report-Immediately, but not later than two hours after the incident occurs or is suspected . Record review of facility's Abuse/Neglect policy (not dated) revealed read in part: .E. Reporting: The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19. a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 8 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 1 out of 18 residents (Resident #21) reviewed for comprehensive care plans. -The facility failed to ensure Resident #21's use of bedrails was added to her individualized care plan. -The facility failed to ensure Resident #21's bed was in a low position. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life, and possible falls leading to injury. Findings include: Record review of Resident #21's admission record dated 11/28/2023 revealed an [AGE] year-old resident admitted on [DATE]. The record documented her diagnoses included aftercare following joint replacement surgery, fracture of the neck of the left femur (break at the top of the long bone in the leg, just below the ball joint), lack of coordination, and dementia (a group of symptoms that affects memory, thinking, and interferes with daily life). Record review of Resident #21's medication report dated 11/28/2023 revealed prescriptions including Acetaminophen 500mg tablet two tablets via G-Tube every eight hours for pain, Donepezil HCl 2mg tablet one tablet via g-Tube at bedtime for depression, Haloperidol 2mg tablet .25ml via G-Tube every six hours as needed for agitation, Lorazepam .5mg tablet one tablet via G-Tube every four hours as needed for anxiety and/or restlessness, and Morphine Sulfate solution 20mg/5ml .25 ml every two hours as needed for severe pain. Record review of Resident #21's annual MDS dated [DATE] with an ARD of 11/8/2023 revealed no BIMS was completed because she was rarely or never understood, she had both short and long-term memory loss, and was moderately impaired in relation to her cognitive skills for daily decision making. The MDS documented she had one side impairment of the lower extremity and required a wheelchair for mobility. Per the MDS, Resident #21 required staff assistance, or was totally dependent on staff, with eating, hygiene, toileting, showering, dressing, transfers, picking up objects, and moving her wheelchair. The MDS documented she received pain medication. The MDS revealed she received both OT and PT. Record review of Resident #21's care plan dated 11/24/2023 revealed a focus on her risk of falls with interventions including proper footwear, education ensuring furniture was in the locked position, and provision of a safe environment with bed in a low position. The care plan documented a focus on her communication problem with interventions including ensuring a safe environment with bed in low position and wheels locked. The care plan did not include a focus or intervention related to her bed rail usage. Observation on 11/28/2023 at 9:20 AM revealed Resident #21's bed was in a normal height position (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 9 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 and bedrails were engaged. Level of Harm - Minimal harm or potential for actual harm Observation on 11/28/2023 at 2:36 PM revealed Resident #21's bed was in a low position and bedrails were engaged. Residents Affected - Some Observation on 11/29/2023 at 8:39 AM of Resident #21 revealed the bed was placed in a normal position and bedrails were engaged. The bed was not lowered to the position observed on 11/28/2023 at 2:36 PM. Interview on 11/28/2023 at 2:36 with the Resident #21's family member, revealed the bed was now in a low position but this was not usual. Resident #21's family member said that was the first time he could recall seeing it in a lowered position. Resident #21's family member said he thought the bed was lowered because of Resident #21's recent fall. Resident #21's family member said the bedrails were typically used. Interview on 11/29/2023 at 8:43 AM with LVN AA, she said Resident #21's bed should have been set in a low position. LVN AA said Resident #21 could fall and injure herself be cause the bed was set in a normal height position. LVN AA said Resident #21 could also reinjure her recently surgically replaced hip. Interview on 11/29/2023 at 2:21 PM with LVN AA, she said a resident's care plan provides interventions for residents' needs. LVN AA said if a care plan was not followed for a resident it could lead to declining health for the resident. Interview on 11/29/2023 at 2:30 PM with MDS Nurse M, she said a care plan ensured continuation of care for a resident. MDS Nurse M said the care plan ensures the staff know what care the residents were supposed to receive. MDS Nurse M said the care plan was created with resident and/or family input to ensure the care was patient specific and centered. MDS Nurse M said a care plan could be contradictory based on the resident's behaviors and actions. MDS Nurse M said Resident #21's care plan documented her bed should be in its lowest position at night and also at all times. MDS Nurse M said based on her review of the care plan, Resident #21's bed should be positioned in its lowest position at all times. MDS Nurse M said since Resident #21 had sustained fractured femur and surgically replaced hip, the bed should be always kept in its lowest position to ensure she did not fall. MDS Nurse M said if the bed was not in its lowest position Resident #21 would likely fall out of the bed. MDS Nurse M said based on the current care plan, Resident #21's bed should be always in its lowest position. Interview on 11/29/2023 at 2:54 PM with the DON revealed she had been employed since March 2023 or April 2023. The DON said her duties included rounding and auditing. The DON said she was responsible for the supervision of the creation and implementation of care plans. The DON said bedrails should be added to the care plan. The DON said bedrails were used to ensure a resident could turn safely. The DON said the MDS nurse should have completed the care plan for the bedrails. The DON said she was responsible for ensuring the bedrail information was correct and in place prior to Resident #21 lying in a bed with bedrails. The DON said Resident #21's bed height should have been resolved when she returned from the hospital after her recent hospitalization and the instillation of a PEG tube. The DON said Resident #21's bed height should be low, but not the lowest position. The DON said because of the PEG tube, if Resident #21's bed was in the lowest position it would be difficult to ensure the PEG tube was utilized correctly. The DON said the MDS nurses update the care plans. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 10 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of the Facility's undated Comprehensive Care Planning policy read in part .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . The care plan required each resident to receive a care plan which addressed his/her preferences and goals. Residents Affected - Some . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 11 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team after each assessment for 1 (Resident #24) of 6 residents reviewed for care plan revisions, in that: -Resident # 24's care plan did not reflect the use of foley catheter. This failure could place residents at risk for not receiving appropriate interventions to meet their current needs. The findings include: Record review of Resident # 24 face sheet (undated) revealed a [AGE] year-old male with admission date of 09/23/2023 and re-admitted on [DATE]. His diagnoses included functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), fusion of spine (this procedure connects two or more bones in the spine) and dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Record review of Resident#24's Quarterly MDS dated [DATE] revealed a BIMS score of 13 out of 15 indicating intact cognition. Further review of MDS revealed Section H-Bladder and Bowel H0100. Appliances: A. indwelling catheter. Record review of Resident #24's care plan initiated on 09/24/23 and revised on 10/18/23 revealed Resident was not care planned for foley catheter and the interventions needed to care for resident. Record review of Resident#24's physician order for the month of November 2023 revealed an order for urinary catheter 16 f/10 cc to gravity drainage every shift. Record review of Resident#24's physician order for the month of November 2023 revealed an order to ensure catheter strap in place and holding every shift change as needed. Record review of Resident#24's physician order for the month of November 2023 revealed an order to provide catheter care every shift. Observation on 11/28/23 at 12:43p.m., revealed Resident # 24 resting on an air mattress. Foley catheter to bedside drainage with yellow urine in the bag. In an interview on 12/01/23 at 10:35 a.m., with CNA JJ, she said catheter care for foley was every shift and as needed. Record review and interview on 11/29/23 at 3:09p.m., with the DON, when asked if the resident should have been care planned for catheter. If so, when should this have been done. Who was responsible for overseeing this. The DON said care plans were completed by the nursing management to include MDS nurses, ADON and herself. She said, I periodically check care plans not every single one. Surveyor reviewed Resident#24's care plan with the DON. The DON said she did not see foley catheter care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 12 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few planned and did not have the interventions needed for the resident. She said, care plan was part of individualized care of plan that we follow. Record review of facility's' Comprehensive Care Planning policy (not dated) revealed read in part: . A comprehensive care plan will be-Developed within 7 days after completion of the comprehensive assessment. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. It does not mean that every goal must have an interdisciplinary approach. The mechanics of how the interdisciplinary team (IDT) meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) is at the discretion of the facility. In instances where an IDT member participates in care plan development, review or revision via written communication, the written communication in the medical record will reflect involvement of the resident and resident representative, if applicable, and other members of the IDT, as appropriate . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 13 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 - Few 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 1 of 5 resident (Resident #60) reviewed for incontinent care. -The facility failed to ensure CNA JJ and CNA RRRR properly cleaned Resident #60 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown, and a decreased quality of life. Findings include: Record review of the admission sheet (undated) for Resident #60 revealed an [AGE] year old female admitted to the facility on [DATE] with diagnoses which included contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), weakness (the state or condition of lacking strength) and parkinson disease ( a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Record review of Resident #60's Quarterly MDS, dated [DATE], revealed the BIMS score was 09 out of 15, which indicated moderately impaired cognitively. The MDS revealed dependent from two staff with transfers, lower body dressing and toileting hygiene. The MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. section H0400: Bowel Incontinence was coded (3) always incontinent. Record review of Resident #60's care plan, initiated 07/21/2023 and revised on 11/11/2023 revealed the following: Focus: The resident has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: INCONTINENT care often and apply moisture barrier after each episode. Observation on 11/30/23 at 10:57a.m., revealed CNA RRRR and CNA JJ provided Resident #60 with incontinence care. CNA JJ removed Resident #60's brief and tucked it under the resident's buttocks. CNA JJ did not spread Resident #60's labia to thoroughly clean the area and the resident's urinary meatus. CNA RRRR assisted Resident #60 to turn onto her left side in order to clean her buttocks. CNA JJ without removing her soiled gloves, tucked clean brief under the resident's buttocks. CNA JJ opened resident's side drawer and looked for a barrier cream. With soiled gloves CNA JJ applied barrier cream on the resident's buttocks. Then, wiped her soiled gloves (that had the barrier cream on) with resident's clean brief and fasten the brief. CNA RRRR and CNA JJ completed perineal care and with the same soiled gloves on, touched the Resident's clean shirt, brief, sheet and blanket. Interview on 11/30/23 at 11:03a.m., with CNA RRRR, she said she did good assisting CNA JJ. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 14 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 - Few CNA JJ should have changed her gloves, washed her hands or used hand sanitizer before placing clean brief on. She said the failure placed the resident at risk for infections. Interview on 11/30/23 at 11:12a.m., with CNA JJ, she said she had been working at the facility since September 2022 as a full-time employee. CNA JJ said she did not spread Resident's labia and clean the resident's meatus during incontinent care. She said she had provided incontinent care to Resident#60 around 7:30am this morning. She said, Resident's brief was soiled. I should have cleaned her properly again. She said the failure placed the resident at risk for infections. She said she recalled doing CNA competency checks for incontinent care at the time of hire. CNA JJ said she had not performed hand hygiene during the delivery of incontinent care to Resident #60 I was nervous. CNA JJ said her actions in not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-service on infection control 6 months ago and could not recall the exact date. Interview on 11/30/23 at 12:13 p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care to prevent UTI. She said CNAs should have either washed or sanitized their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said CNAs were provided training and competency check offs quarterly and annually. She said the ADONs were in process of performing the competency check off with CNAs as part of survey preparation. She said she asked CNA JJ if she had completed CNA competency check off with the ADON and CNA JJ told her no. She said these failures were risk for infection control. She said staff received training/in-service on infection control every day. Record review of facility's Perineal Care policy (effective 05/11/2022) revealed read in part: .Purpose- This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Procedure Content-16) Wipe across the pubis area. 17) Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area CLEAN to DIRTY! Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protect the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about 3 inches. Then wipe the other side. Use a clean area of the washcloth or pre-moistened cleansing wipes for each stroke. Important Points-Always perform hand hygiene before and after glove use . Record review of facility's Nurse Aide Incontinence Care Proficiency Assessment (not dated) revealed read in part: .makes first long wipe at top of pubis area (moving towards self). separates inner labia swipes front to back. washes rest of perineal area working side to side using clean wipe with each swipe. washes hands/changes gloves . Record review of facility's C.N.A Proficiency: Perineal Care (with/without catheter) (not dated) revealed read in part: .Female: Separates inner labia, wipes skin using a different surface with every wipe. Female: Wipes from front to back. Female: Wipes outward towards the thighs, using a clean surface of wipe/washcloth each time. Washes hands and changes gloves . Record review of facility's Infection Control Plan: Overview (Infection Control Policy & Procedure Manual 2019) revealed read in part: .Infection Control-The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 15 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 - Few INTENT- Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination . Record review of facility's Fundamentals of Infection Control Precautions (not dated) revealed read in part: .Hand Hygiene -Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: After removing gloves. Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. It is necessary for staff to have access to proper hand washing facilities with available soap (regular or anti-microbial), warm water, and disposable towels and/or heat/air drying methods. Alcohol based hand rubs (ABHR) cannot be used in place of proper hand washing techniques in a food service setting . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 16 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0692 Provide enough food/fluids to maintain a resident's health. 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 acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 6 residents (Resident #54) reviewed for nutritional status. Residents Affected - Some The facility failed to remove Residents #54's mighty shake from her meal ticket in accordance with Dietitian recommendations and Physician orders. This failure could place residents at risk of weight gain. Findings include: Record review of Resident #54's admission record dated revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, cognitive communication deficit, hypertension (high blood pressure), epilepsy, and pain. Record review of Resident #54's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 5 out of 15 which indicated severe cognitive impairment. She required set up or clean up assistance with meals. Record review of Resident #54's Communication between the Dietitian and the Attending Physician letter dated 8/20/23 written by the Dietitian revealed she had significant weight gain of 8% for 1 month (11.8 pounds), 19.6% for 3 months (26 pounds). Good intake with meals, supplement not needed. The recommendation was to discontinue health shakes every shift. The form was signed by the NP on 9/1/23. Record review of Resident #54's dietary note dated 8/21/23 written by the Dietitian revealed the resident's weight was 159.8 pounds and BMI was 24.3. Her ideal body weight was 140 pounds. Record review of Resident #54's dietary note dated 9/30/23 written by the Dietitian revealed the resident had weight gain 16.2% for 3 months (22.6 pounds). Her weight was 161.8 pounds and BMI was 24.6. Record review of Resident #54's dietary note dated 10/24/23 revealed the resident had weight gain of 13.4 % for 3 months (19.6 pounds), 22% for 6 months (30 pounds) - trending up 4.4 pounds for 1 month. Her weight was 166.2 pounds and BMI 25.3. Record review of Resident #54's Care Plan Conference dated 11/9/23 read in part, .Resident has had a weight gain and RP is concerned and does want snacks decreased between meals . Record review of Resident #54's dietary note dated 11/26/23 written by the Dietitian revealed she had weight gain of 26.1% for 6 months (34.5 pounds). Trending up 8.2 pounds for 3 months. Her weight was 166.6 and BMI 25.3. Record review of Resident #54's Order Summary Report dated 12/1/23 revealed she was on a regular diet, order date 11/1/23. There was no order for mighty shakes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 17 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0692 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #54's Order Audit Report dated 12/1/23 revealed House shakes every shift for supplement was discontinued on 8/23/23 by ADON A. Interview on 11/28/23 at 11:30 a.m. with Resident #54's RP, she said the facility needed to remove the shakes from the resident's meals because she was gaining too much weight. Residents Affected - Some Observation and interview on 11/28/23 at 12:44 p.m. of Resident #54's lunch ticket dated 11/28/23 revealed a mighty shake was listed on it. There was a strawberry shake sitting on the resident's dresser. Resident #54's RP said it came with her meal tray and she moved it to the dresser. Observation and interview on 11/30/23 at 8:36 a.m. of Resident #54 in the dining room eating breakfast. Her meal ticket had a mighty shake listed on it. Resident #54 ate her food and drank the shake and said everything was pretty good. Observation on 11/30/23 at 9:14 a.m. revealed Resident #54's vanilla shake contained 200 calories. Interview on 11/30/23 at 9:16 a.m. with the Dietary Manager, she said the nursing department notified them of the dietary orders needed for the residents. She said she did not have an order to discontinue a mighty shake for Resident #54. She said a mighty shake provided extra calories and was used for supplements and weight loss. Interview on 11/30/23 at 11:06 a.m. with the ADON, she said she oversaw the weights. She said the Dietitian emailed her and the DON dietary recommendations. She said she placed the recommendations in a binder for the MD to sign, update the orders, and update the meal tickets to send to dietary. She said she did not remember seeing the discontinue order for Resident #54's health shakes. She said mighty shakes helped residents gain weight. She said she knew Resident #54 was gaining weight but did not know she was on the health shakes. She said her house (mighty) shakes order was discontinued on 8/23/23 but she did not know if it was communicated to the kitchen. Interview on 11/30/23 at 4:10 p.m. with the Administrator, he said his expectation was for dietary and nursing to communicate during the morning meeting. Interview on 12/01/23 12:52 p.m. with the DON, she said the kitchen needed an order to provide a mighty shake to a resident. She said dietary should not give the shake without a physician's order. She said mighty shakes were for weight gain and to help residents who were below their weight goal. Record review of the facility's Resident Weight policy dated 2/13/2007 read in part, .8. Significant weight gain. A significant weight change will be defined as 5% or greater in one month, 7.5% or greater in three months, or 10% or greater in six months . All physician orders will be initiated. 9. All significant weight changes will be referred to the Regional Dietitian on the next visit . The Regional Dietitian will review all facility interventions, and will make appropriate recommendations, which will be approved by the physician, if necessary . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 18 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0695 Provide safe and appropriate respiratory care 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 reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 (Resident #23) of 4 residents reviewed for respiratory care, in that: Residents Affected - Few -Resident #23's Nebulizer mask was not changed in over 14 days. This failure could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Include: Record review of Resident #23's Face Sheet (undated) revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (occurs when the lungs can't release enough oxygen into your blood) pulmonary fibrosis (serious lung disease that causes lung scarring and shortness of breath) and hypoxemia (low levels of oxygen in your blood). Record review of Resident #23's Comprehensive MDS assessment dated [DATE] revealed she was assessed as having a BIMS of 15 out of 15 indicating intact cognitively. The MDS did not indicate respiratory status. Record review of Resident #23's care plan initiated 02/11/2021 and revised on 06/28/2023 revealed the following: Focus: The resident has Oxygen Therapy as needed Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions/Tasks: Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. Oxygen at 2-4_lpm per nasal canula as needed. Prevent abdomen compression and respiratory embarrassment by routinely checking the residents position so that he or she does not slide down in bed. Resident was not care planned for receiving PRN breathing treatments. Record review of Resident #23's physician order dated 11/01/23 revealed an order to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 milliliter inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer. This order was discontinued on 11/28/23. Record review of Resident #23's physician order dated 11/28/23 revealed an order to administer Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium- Albuterol) 1 vial inhale orally every 4 hours as needed for COPD. Record review of Resident #23's MAR/TAR for the month of November 2023 revealed resident received PRN Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium- Albuterol) on 11/01/23, 11/02/23, 11/03/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, 11/16/23, 11/20/23, 11/21/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 19 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0695 11/22/23, 11/24/23, 11/25/23, 11/26/23 and 11/28/23. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #23's physician order dated 11/29/23 revealed an order to change nasal canula as needed change when visibly soiled. Residents Affected - Few Observation and interview on 11/28/23 at 12:26 p.m., with LVN FFFF revealed Resident #23 was resting on her bed receiving breathing treatment. LVN FFFF said Resident #23's neb mask was dated for 11/13/23. LVN FFFF said nebulizer mask and tubing was supposed to be changed every 2 weeks by the night shift nurse. She said she had started working at this facility in July 2023. She had not received training on labeling/dating oxygen tubing/neb mask at this facility. She said, I have learned in nursing school we have to change the tubing. She said the risk of not changing the neb mask was infections. Interview on 11/28/23 at 2:02p.m., with the DON, she said there was a standing order to change oxygen tubing/neb mask every Sunday by night shift nurse. She said there was no place on the MAR or TAR for nurses to sign off after the nurse changed the tubing. When asked how she would know if nurses were changing out the tubing/neb mask weekly she said, the nurses should be checking the date prior to administering the treatment. She said the risk of not changing the neb mask was URI. The DON said the facility did not have policy on labeling/dating oxygen therapy equipment we do not label our tubing. Record review of facility's Aerosolized Hand-Held Nebulizer policy (not dated) revealed read in part: . Purpose: To provide guidelines for administration of nebulized medication to patients. Procedure: 15. Change nebulizer set-up every 7 days and more often if necessary . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 20 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was assessed and had consents for bed rails for 1 of 6 residents (Resident #21) reviewed for bed rails. -The facility failed to obtain consent prior to installing and utilizing bedrails for Resident #21. -The facility failed to complete an assessment prior to installing and utilizing bedrails for Resident #21. These failures could affect residents who utilized some type of bed rails in the facility and could put the residents at risk for potential injuries. Findings include: Record review of Resident #21's admission record dated 11/28/2023 revealed an [AGE] year-old resident admitted on [DATE]. The record documented her diagnoses included aftercare following joint replacement surgery, fracture of the neck of the left femur (break at the top of the long bone in the leg, just below the ball joint), lack of coordination, and dementia (a group of symptoms that affects memory, thinking, and interferes with daily life). Record review of Resident #21's medication report dated 11/28/2023 revealed prescriptions including Acetaminophen 500mg tablet two tablets via G-Tube every eight hours for pain, Donepezil HCl 2mg tablet one tablet via g-Tube at bedtime for depression, Haloperidol 2mg tablet .25ml via G-Tube every six hours as needed for agitation, Lorazepam .5mg tablet one tablet via G-Tube every four hours as needed for anxiety and/or restlessness, and Morphine Sulfate solution 20mg/5ml .25 ml every two hours as needed for severe pain. Record review of Resident #21's annual MDS dated [DATE] with an ARD of 11/8/2023 revealed no BIMS was completed because she was rarely or never understood, she had both short and long-term memory loss, and was moderately impaired in relation to her cognitive skills for daily decision making. The MDS documented she had one side impairment of the lower extremity and required a wheelchair for mobility. Per the MDS, Resident #21 required staff assistance, or was totally dependent on staff, with eating, hygiene, toileting, showering, dressing, transfers, picking up objects, and moving her wheelchair. The MDS documented she received pain medication. The MDS revealed she received both OT and PT. Per the MDS, Resident #21 did not use bed rails. Record review of Resident #21's care plan dated 11/24/2023 revealed a focus on her risk of falls with interventions including proper footwear, education ensuring furniture was in the locked position, and provision of a safe environment with bed in a low position. The care plan documented a focus on her communication problem with interventions including ensuring a safe environment with bed in low position and wheels locked. The care plan did not include a focus or intervention related to her bed rail usage. Record review of Resident #21's EMR, revealed no bedrail consent or bedrail assessment was observed until 11/29/2023 after surveyor intervention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 21 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0700 Level of Harm - Minimal harm or potential for actual harm Observation on 11/28/2023 at 9:20 AM revealed Resident #21's bed was in a normal height position and one-half style bedrails were engaged. Observation on 11/28/2023 at 2:36 PM revealed Resident #21's bed was in a low position and one-half style bedrails were engaged . Residents Affected - Some Observation on 11/29/2023 at 8:39 AM of Resident #21 revealed the bed was placed in a normal position one-half style and bedrails were engaged . The bed was not lowered to the position observed on 11/28/2023 at 2:36 PM. Interview on 11/28/2023 at 2:36 with Resident #21's family member revealed the bed was now in a low position, but this was not usual. Resident #21's family member said that was the first time he could recall seeing it in a lowered position. Resident #21's family member said he thought the bed was lowered because of Resident #21's recent fall. Resident #21's family member said the bedrails were typically used. Interview on 11/29/2023 at 2:54 PM with the DON revealed she had been employed since March 2023 or April 2023. The DON said her duties included rounding and auditing. The DON said if a resident was using bedrails, the resident should have a bedrail assessment completed prior to their install. The DON said bedrails were used to ensure a resident could turn safely, but the bedrail assessment should be completed prior to the installation. The DON said she was unsure why Resident #21 did not have a bedrail assessment completed prior to their installation. The DON said she was responsible for ensuring the bedrail information was correct and in place prior to Resident #21 lying in a bed with one-half style bedrails. The DON said after reviewing her EMR, there was neither a bedrail assessment nor a bedrail consent for Resident #21. The DON said Resident #21 should have had a bedrail assessment and a bedrail consent prior to their instillation. The DON said the bedrail assessment and consents were utilized to ensure the bedrails were needed, safe, and the RP agreed to the use of the bedrails. Record review of the facility's Bed Rails ` policy dated 11/8/2016 revealed a policy statement which read This facility will utilize bed rails for those residents that use them for bed mobility. The policy documented the facility would attempt to use alternative measures prior to the utilization of bedrails. Per the policy, the facility would complete an assessment prior to bedrail use to ensure the bedrails were appropriate for the resident. The policy required consent from the resident and/or the RP prior to bedrail usage. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 22 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 observation, interview, and record review the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 (skilled unit nurses' cart) of 4 medication carts reviewed for controlled drugs. The facility failed to document that one of Resident #47's ten morphine syringes contained 0.5 mL instead of 0.25 mL. The 0.5 mL syringe was rubber banded together with the 0.25 mL syringes. This failure could result in a medication error or drug diversion. Findings include: Record review of Resident #47's face sheet dated 12/1/23 revealed a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Alzheimer's disease, pain, and depressive disorder. Record review of Resident #47's annual MDS assessment dated [DATE] revealed she had a BIMS score of 6 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #47's care plan revised on 11/18/23 revealed she was on pain medication therapy related to age related joint pain. Her interventions were to administer mediation as ordered. Record review of Resident #47's Order Summary Report dated 12/1/23 revealed an order for morphine sulfate 5 mg/mL give 0.25 mL sublingually every 4 hours as needed for pain. There was no order for 0.5 mL. Record review of Resident #47's undated Controlled Substance Log for Morphine Sulfate Prefilled syringes 20 mg/mL revealed the last recorded entry was on 8/9/23 and there were 6 syringes left. The handwritten drug information on the control log did not specify how many milliliters were in each prefilled syringe. In an observation and interview on 12/1/23 at 11:31 a.m. of the skilled unit nurses' cart with LVN T revealed there were 6 prefilled morphine syringes rubber banded together in a Ziploc bag with Resident #47's name written on it. 5 prefilled syringes had 0.25 mL of Morphine and 1 prefilled syringe had 0.5 mL. The label attached to the 0.5 mL syringe read Morphine 20 mg 0.5 mL. LVN T said she did not notice that the one syringe had a different amount of Morphine during the narcotic count at shift change. She said she ensured the number of syringes in the bag matched the number of syringes on the control log. She said the syringes should not have been grouped together because it was not the same dose, and it could cause a medication error. Interview on 12/1/23 at 11:51 a.m. the DON said she expected all narcotics to match the control sheet and to be accounted for. She said nursing staff should count the prefilled syringes and verify that the dosage is correct during shift count. She said if there was a discrepancy, nurses should notify her so she could investigate. She said the 0.25 mL and the 0.5 mL Morphine syringes should not be connected because a medication error could occur if the staff were not careful. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 23 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 In a continued interview on 12/1/23 at 12:52 p.m. the DON said the pharmacy must have sent the facility the incorrect dose because the syringes had the same lot number. She said each nurse was responsible for ensuring the accuracy of the dosage once received from the pharmacy. She said she oversaw the nurses. Record review of the facility's Controlled Drugs Audit and Accountability policy dated 2003 read in part, .3. The Accountability Audit of Controlled Drug Audit Sheets record will be filled in with the information that corresponds to the Rx supply. Staff will note how many doses were given and how many doses remain. 4. The change of shift audit sheets is where nursing staff will sign to indicate that the controlled drugs were audited and that the responsibility of accountability of the controlled drugs is being changed to a different nursing staff . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 24 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0759 Ensure medication error rates are not 5 percent or greater. 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 that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 26 opportunities, which involved 1 (Resident #57) of 6 residents reviewed for medication errors in that: Residents Affected - Few -MA E administered Celecoxib (a medication used to treat pain or inflammation) to Resident #57 without a physician's order and did not administer Vitamin D to Resident #57 as ordered by the physician. These failures could place residents at risk of inadequate therapeutic outcomes. Findings include: Resident #57 Record review of Resident #57's face sheet dated 12/1/23 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included age-related osteoporosis (a condition when bone strength weakens and is susceptible to fracture), fracture of right femur, subsequent encounter for closed fracture with routine healing, dementia, and muscle weakness. Record review of Resident #57's annual MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15, which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #57's Order Summary Report for December 2023 revealed an order for Cholecalciferol (vitamin D) 1000 unit give 1 tablet by mouth one time a day for supplement, order date 8/17/23. There was no order for Celecoxib. Record review of Resident #57's nursing note dated 11/27/23 written by LVN AA read in part, Resident's (family member) was concerned that the resident was taking too much pain reliever . notified NP (name) stated to d/c Celebrex (Celecoxib) . Record review of Resident #57's Order Audit Report dated 11/29/23 revealed Celecoxib 100 mg was discontinued on 11/27/23. Observation on 11/29/23 at 10:34 a.m. revealed MA E prepared Resident #57's medication for administration. MA E's electronic MAR showed Celecoxib 100 mg in white and had the letters d/c in red. MA E prepared Celecoxib 100 mg - 1 capsule, Senna 8.6 mg - 1 tablet, Furosemide 20 mg - 1 tablet, Lisinopril 5 mg - 1 tablet and Artificial tears eye drops. MA E said she had 4 pills total. She entered the activities room and administered the medication to Resident #57. MA E returned to her cart and documented that the medications were administered. MA E did not administer Vitamin D as ordered and administered Celecoxib without a physician's order. Interview on 11/29/23 at 10:56 a.m. MA E said she did not give Vitamin D to Resident #57 because she missed it. She said she normally checked the computer and pills twice for medication name and milligrams. She said she was not supposed to administer discontinued medications. She said the medication should have been removed from the cart and placed in the medication room because it was not supposed to be given. She said because the Celecoxib was in white there was no option to document that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 25 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 0759 medication was administered to Resident #57 in the system. Level of Harm - Minimal harm or potential for actual harm Interview on 11/29/23 at 3:34 p.m. the DON said nursing staff should compare the medication name and dosage to the information on the eMAR. She said the medication aide should click yes on the eMAR after placing the medication in the cup. She said Resident #57's Celebrex (celecoxib) was discontinued on the 27th and discontinued medications do not pop up on the eMAR unless it has not fallen off. She said medications listed in white should not be given because the doctor discontinued the medication. She said discontinued medications should be pulled from the cart and placed in a box in the medication room to avoid a medication error. Residents Affected - Few Record review of the facility's policy Medication Administration Procedures dated 10/25/2017 read in part, . 20. The 10 rights of medication should always be adhered to: . 2. Right medication, 3. Right dose 7. Right documentation . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 26 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 2 of 2 facility refrigerators reviewed for food procurement. - The facility failed to discard expired and unlabeled food items in the kitchen and nourishment room refrigerators. -The facility failed to store food according to manufacturer instructions. These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness and cross-contamination. Findings include: Observation on 11/28/23 at 8:40 am revealed the walk-in refrigerator had a foul odor upon entry. Observed zucchini in a box labeled with 11/8 with fuzzy, white, mold-like substance on the stalk of the vegetables. Observed packaged fresh basil in a box labeled 11/1. The basil was discolored with dark brown leaves mixed among green leaves. Observed box of bagged, fresh collard greens. The box was labeled 11/1 and the bags of greens was dated with best by 11/13/23. The collard greens were identified as the source of foul odor. Observed a box of garlic toast that said Keep Frozen in the Walk-In Refrigerator. The bread was thawed. Interview on 11/28/23 at 8:50 AM, [NAME] R said the garlic toast was taken out yesterday because she prepared it with a meal. It just did not make it back to the freezer. She said that failure to store food properly was that it can go bad or make someone sick. She said she was unaware of the old produce in the walk-in refrigerator. She said old, unusable, or outdated food should be discarded, so they do not get used and potentially make someone sick. Interview on 11/28/23 at 8:57AM with the DM, she acknowledged that the basil was no good and that the collard greens were not good. She said she thought the fuzz on the zucchini might be wax. She said that all of the kitchen staff were responsible for discarding old food. She said that she checks once or twice per week on Monday or Tuesday when doing inventory and the cooks were in and out of the refrigerators daily , so they should be checking then as well. She said the garlic toast was taken out of the freezer because the cooks were using it the day prior. She had no response as to why it was not placed back into the freezer. She said failure to store food properly or discard old food is that it can make someone sick. Interview on 11/29/23 at 8:56 AM with the Administrator said that his expectation was for kitchen staff to be cleaning out the refrigerator daily and discarding anything not in-date or not good as it was part of their job to do so. He said he does not think that the old food in the refrigerator would impact the residents because the cooks would realize it was not good if they went to use it and would discard it among finding it was not good. Record review of Food Storage and Supplies Policy (undated) read in part: . 6. Any product with a stamped expiration date will be discarded once that date passes . 8. Spoiled foods will develop an off odor, flavor or texture due to naturally occurring spoilage bacteria . if possible food spoilage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 27 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 is observed prior to the best by date, the product will be discarded . Level of Harm - Minimal harm or potential for actual harm Observation on 12/01/23 at 9:30 AM revealed the nourishment room refrigerator (resident food only) contained a bag of rotisserie chicken with foul odor labeled with resident name and room number, an unlabeled container with 4 pieces of cake, and 4 bottles of unopened, spoiled whole milk with resident name and room number- use by 09/13/2023. Residents Affected - Some Interview on 12/01/23 at 9:37 AM the DON and the Administrator said that housekeeping was responsible for cleaning out the nourishment room refrigerator. The administrator said that it should be cleaned out regularly. Interview on 12/02/23 at 9:40 AM the HK Sup said it was important to label and discard old food so that no one gets sick. Record review of Menu Approval and Honoring Resident Special Requests, and Food Brought to the Facility from Unapproved Sources Policy (undated) read in part . 2. If a family member or other visitor or staff brings prepared, potentially hazardous (time and temperature controlled for safety) food items for a resident, these items cannot be stored in the dietary department . These items can be stored in the individual resident room or other approved areas available depending on the food item . This policy did not address storage conditions or how to label food brought into the facility by outside sources. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 28 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 18 residents (Resident #60) reviewed for infection. Residents Affected - Some -The facility failed to ensure CNA JJ and CNA RRRR performed hand hygiene during incontinent care on Resident #60. -The facility failed to ensure CNA BB used hand hygiene when passing meals to residents. These failures could lead to the spread of infection to residents, resident illness, and/or resident distress. Finding include: Observation on 11/28/2023 at 12:43 PM, the memory care unit's meal trays arrived at 12:43 PM. CNA BB began to pass the trays to one of the two dining areas of the unit. CNA BB placed a tray on the table for a resident in the room. CNA BB then moved a resident's wheelchair into the dining room and parked the chair at a table. CNA BB locked the wheels using the lock mechanism and touched the wheels of a resident's wheelchair. CNA BB then moved another resident into the dining room, locking the wheelchair, and touched that resident's wheelchair's wheels. CNA BB immediately began to pass the remaining trays to residents in the dining room, opening the containers, removing the plastic wrap from plates of vegetables, opened and passed silverware to residents, and opened resident's drinks. CNA BB did not wash her hands or use hand sanitizer between moving the residents and touching the wheelchairs, wheels, and locking mechanisms and passing the food to the residents. Interview on 11/28/2023 at 12:54 PM with CNA BB revealed she had been employed for three months. CNA BB said she had received training related to meal pass. CNA BB said she was trained to set the meal trays up for the residents, check the meal tickets to ensure the meal was correct, and assist residents in eating who required assistance. CNA BB said she should have used hand sanitizer or washed her hands after she parked two wheelchairs, and touched the brakes and wheels, before passing any more trays. CNA BB said she should have washed her hands because she touched the chairs and could possibly pass germs to the residents. Record review of the admission sheet (undated) for Resident #60 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses which included contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), weakness (the state or condition of lacking strength) and Parkinson's disease ( a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Record review of Resident #60's Quarterly MDS, dated [DATE], revealed the BIMS score was 09 out of 15, which indicated moderately impaired cognitively. The MDS revealed dependent from two staff with transfers, lower body dressing and toileting hygiene. The MDS revealed in section H0300: Urinary Incontinence was coded (3) always incontinent. section H0400: Bowel Incontinence was coded (3) always incontinent. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 29 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 Residents Affected - Some Record review of Resident #60's care plan, initiated 07/21/2023 and revised on 11/11/2023 revealed the following: Focus: The resident has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: INCONTINENT care often and apply moisture barrier after each episode. Observation on 11/30/23 at 10:57a.m., revealed CNA RRRR and CNA JJ provided Resident #60 with incontinence care. CNA JJ removed Resident #60's brief and tucked it under the resident's buttocks. CNA JJ did not spread Resident #60's labia to thoroughly clean the area and the resident's urinary meatus. CNA RRRR assisted Resident #60 to turn onto her left side in order to clean her buttocks. CNA JJ without removing her soiled gloves, tucked clean brief under the resident's buttocks. CNA JJ opened resident's side drawer and looked for a barrier cream. With soiled gloves CNA JJ applied barrier cream on the resident's buttocks. Then, wiped her soiled gloves (that had the barrier cream on) with resident's clean brief and fasten the brief. CNA RRRR and CNA JJ completed perineal care and with the same soiled gloves on, touched the Resident's clean shirt, brief, sheet and blanket. Interview on 11/30/23 at 11:03a.m., with CNA RRRR, she said she did good as far as assisting CNA JJ. She said CNA JJ should have changed her gloves, washed her hands, or used hand sanitizer before placing clean brief on. She said the failure placed the resident at risk for infections. Interview on 11/30/23 at 11:12a.m., with CNA JJ, she said she had been working at the facility since September 2022 as a full-time employee. CNA JJ said she did not spread Resident's labia and clean the resident's meatus during incontinent care. She said she had provided incontinent care to Resident#60 around 7:30am this morning. She said, Resident's brief was soiled. I should have cleaned her properly again. She said the failure placed the resident at risk for infections. She said she recalled doing CNA competency checks for incontinent care at the time of hire. CNA JJ said she had not performed hand hygiene during the delivery of incontinent care to Resident #60 I was nervous. CNA JJ said her actions in not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-service on infection control 6 months ago and could not recall the exact date. Interview on 11/30/23 at 12:13 p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care to prevent UTI. She said CNAs should have either washed or sanitized their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said CNAs were provided training and competency check offs quarterly and annually. She said the ADONs were in process of performing the competency check off with CNAs as part of survey preparation. She said she asked CNA JJ if she had completed CNA competency check off with the ADON and CNA JJ told her No. She said these failures were risk for infection control. She said staff received training/in-service on infection control every day. Interview on 11/30/2023 at 2:07 PM with LVN MM, she said her duties included taking vital signs, floating to whichever hall she was needed at, passing medications, assisting CNA's, charting, glucose finger sticks, insulin administration, and tube feedings. LVN MM said the primary means to ensure infection control was through hand washing, hand hygiene, and glove use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 30 of 31 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 676239 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Toscana at Cypress Woods 15015 Cypress Woods Medical Dr Houston, TX 77014 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 Residents Affected - Some Interview on 11/30/2023 at 2:27 with CNA TTTT revealed he had been employed for two-and-a-half months. CNA TTTT said his primary duties included caregiving, feeding, incontinence care, and transfers of residents. CNA TTTT said the primary manner to ensure infection control was through hand washing. Interview on 12/1/2023 at 10:07 AM with the DON, she said the primary manner to ensure infection control and stop the spread of infection was through hand washing. The DON said staff should wash their hands prior to entering a room, before touching a resident, or if the staff touch anything soiled. The DON said staff should wash their hands prior to passing trays and between each resident. Record review of facility's Infection Control Plan: Overview (Infection Control Policy & Procedure Manual 2019) revealed read in part: .Infection Control-The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. INTENT- Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination . Record review of the facility's Fundamentals of Infection Control Precautions policy dated 2019 revealed a policy statement which read A variety of infection control measures are sued for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. The policy documented hand hygiene was the primary means of preventing the transmission of infection. Per the policy hand hygiene was to be used in situations including: When coming on duty; When hands are visibly soiled (hand washing with soap and water);Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); Before and after eating or handling food (hand washing with soap and water); Before and after assisting a resident with meals; and After handling soiled equipment or utensils. The policy read in part .Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. It is necessary for staff to have access to proper hand washing facilities with available soap (regular or anti-microbial), warm water, and disposable towels and/or heat/air drying methods. Alcohol based hand rubs (ABHR) cannot be used in place of proper hand washing techniques in a food service setting . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676239 If continuation sheet Page 31 of 31