Health inspection·April 15, 2025

F 0656 . C. Bowel and Bladder. 1. Urinary continence - Always continent . 4. Bowel and bladder appliances Indwelling catheter . Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's physician's orders for February 2025 - April 2025 revealed the following: Residents Affected - Few * Flush [catheter] with 60cc's NS every day, PRN, every shift. Start date: 02/01/2025. End date: 02/11/2025. * [Catheter] care: Output Q shift every day and night shift. Start date: 02/01/2025. End date 02/11/2025. * Change [Catheter] and drainage bag PRN for obstruction or when closed system is compromised as needed. Start date: 02/25/2025. End date: 03/07/2025. * Flush [catheter] with 60cc's NS every day, PRN, as needed. Start date: 02/26/2025. End date: 03/07/2025. * Flush [catheter] with 60cc's NS every day, PRN, every shift. Start date: 03/18/2025. End date: 04/11/2025. * [Catheter] care: Output Q shift every day and night shift. Start date: 03/17/2025. End date 04/09/2025. Reason: [Catheter] discontinued. * Remove [catheter], if not voided in 8 hours, replace [catheter] one time only for 1 day, remove at 3:00 p.m. Order date 04/09/2025. End date: 04/10/2025. Record review of Resident #1's comprehensive care plan, revised 04/09/2025 revealed the following care areas: * [Resident #1] has acute renal failure. Goal included: [Resident #1] will have no s/sx of complications related to fluid deficit (dehydration - when the body loses more fluid than it takes in). Interventions included: Give medications as ordered by physician. Monitor changes in mental status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 Monitor for s/sx of infection, UTI. Monitor lab reports of electrolytes and report to physician. Level of Harm - Minimal harm or potential for actual harm * Residents Affected - Few [Resident #1] has incontinence and limited mobility due to his multiple comorbidities putting him at risk for skin breakdown. Goal included: The resident will maintain or develop clean and intact skin. Interventions included: Encourage good nutrition and hydration. Keep skin clean and dry. * [Resident #1] has urinary incontinence putting him at risk for having a UTI. Goal included: Resident #1's risk for septicemia (blood poisoning - a bloodstream infection where bacteria and their toxins are carried throughout the body) will be minimized/prevented via prompt recognition and treatment of symptoms of UTI. Interventions included: Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Ensure the resident has an unobstructed path to the bathroom. Incontinent: Check every 2 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. * [Resident #1] is at risk for renal insufficiency due to him having chronic kidney disease stage 4. Goal included: Resident #1 will have no s/sx of complications related to fluid deficit. Interventions included: Monitor/document/report PRN any s/sx of acute renal failure. Further review of Resident #1's comprehensive care plan revealed no care area to address his indwelling urinary catheter. Record review of Resident #1's nursing progress notes for January 2025 - April 2025 revealed the following: * On 01/29/2025 at 6:00 a.m., an unidentified staff member wrote, admission details: Arrived by: ambulance. admission mode: stretcher . * On 01/30/2025 at 4:14 p.m., RN C wrote, Re-admit day 2/3 (Resident #1 was readmitted to the facility on [DATE]. There was no documentation about a catheter before this date). Resident is alert and oriented to self and situation . Resident's [catheter] is patent and draining clear, yellow urine. No color noted . * On 02/09/2025 at 1:01 a.m., LVN B wrote, . Genitourinary (urinary and genital organs): Catheter character: Patent (open or unobstructed). Catheter in place due to urinary retention (the inability to completely empty the bladder when urinating). Catheter size: 16 . * (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 - Few On 04/09/2025 at 4:55 a.m., LVN A wrote, Late Entry. Resident [catheter] discontinued per RP request and NP orders and tolerated well. Will monitor urine output through night per orders to reinsert if output not sufficient. Observation and interview with Resident #1 on 04/11/2025 at 1:05 p.m. revealed he was alert and spoke Spanish. Through an interpreter with the HHSC approved language line, Resident #1 provided his name and birthdate. He did not have a catheter at that time. In an interview with the DON on 04/15/2025 at 10:45 a.m., she stated Resident #1 had a catheter at one time, but it was removed last week. She said she could not recall why Resident #1's catheter was removed, but she did not think he had it for a long time. In a follow-up interview with the DON on 04/15/2025 at 12:58 p.m., she stated Resident #1 may have returned from the hospital with the catheter on 3/17/2025. She said Resident #1's catheter should have been listed as a care area on his care plan to inform staff how to care for it and to communicate what was going on with him. She said she was surprised to hear that Resident #1's catheter was not mentioned on his care plan. She stated the MDS Nurse was responsible for updating care plans and she was going to ask the MDS Nurse why there was no care area related to Resident #1's catheter. In an interview with Resident #1's Physician on 4/15/2025 at 1:28 p.m., she stated her records indicated Resident #1 first had the catheter around 02/08/2025 due to urinary retention. She said the purpose of a care plan was to ensure staff knew what to do regarding the care areas, like Resident #1's catheter. She said staff never contacted her about any issues with Resident #1's catheter. She said as far as she knew, Resident #1's family requested to remove the catheter because they were taking him home. In an interview with the MDS Nurse on 04/15/2025 at 2:30 p.m., she stated she was responsible for updating residents' care plans. She said she and her assistant received information from morning staff meetings and the DON gave them lists of residents with feeding tubes, catheters, and tracheostomy tubes (a surgical procedure that creates an opening in the neck to insert a tube directly into the trachea). She said if any resident had a change in condition, she or her assistant would update their care plan. The MDS Nurse initially stated her assistant resolved (removed from the care plan) Resident #1's catheter information on 04/11/2025. She said Resident #1 was readmitted on dialysis on 03/17/2025, so she and her assistant completed a significant change assessment (completed a significant change MDS). She stated any resolved care area on a care plan would still be visible in their computer system. After reviewing Resident #1's comprehensive care plan on her computer, the MDS Nurse stated she did not see any care area related to Resident #1's catheter. She stated she was on leave when Resident #1 readmitted , but she heard the team (the nursing staff) talk about Resident #1 when she returned to work. The MDS Nurse stated she did not see any care area related to Resident #1's catheter which would have resolved from the care plan. She said Resident #1's catheter was addressed on his MDS and baseline care plan, but it did not carry over to his comprehensive care plan. She said the purpose of the care plan was to ensure all the staff knew each residents' plan of care and what interventions were in place. She said the care plan was also for new staff who were not familiar with the residents. She stated there were no negative effects related to Resident #1's catheter not being addressed on his care plan, but a negative effect would be that staff would not know information, like when to change him or how to care for him, and that could lead to infection. In an interview with the DON on 04/15/2025 at 3:00 p.m., she said Resident #1 had the catheter in February 2025. She said Resident #1 was discharged to the hospital and returned with the catheter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete She stated Resident #1 did not experience any negative effects from not having the catheter addressed on his care plan because the staff followed orders from his physician. She said a negative effect would be infection. Record review of the facility's policy, titled, Care Plans, Comprehensive Person-Centered revised March 2022 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . c. includes the resident's stated goals upon admission and desired outcomes; . e. Reflects currently recognized standards of practice for problem areas and conditions . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; . c. when the resident has been readmitted to the facility from a hospital stay . Event ID: Facility ID: 676252 If continuation sheet Page 5 of 5