Health inspection·May 19, 2024

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interventions: Eating: the resident requires (supervision) with setup. Toilet use: the resident requires (extensive assistance) by (1) staff for toileting. Dressing: the resident requires (extensive assistance) by (1) staff to dress. Record review of CR#1's Nurses note dated 5/8/24 at 12:29pm written by LVN A revealed read in part: .Note Text: Nurse entered room and observed resident gurgling and with yellow emesis on her gown Nurse called resident name; resident was not responding Nurse initiate V/S BP 120/42 P 47 BS 194 O2 Sat 90% on RA. Resident V/S Rechecked BP 112/52 P 58 O2 Sat 83% oxygen applied NP is here to assesses Resident. Resident O2 Sat 74% non-rebreather is applied. NP gave order to send Resident out 911 to [Hospital name]. Resident Guardian is contacted but there was no answer, This Nurse left a voice message to call facility at her earliest convenience . Record review of CR#1's NP's notes dated 5/8/24 revealed read in part: .Chief Complaint: acute visit. History of Present Illness: Polite 57F long term nursing home resident. Nurse called me to see the resident for sudden change in condition. Per nurse, she had breakfast and medications in am as usual. But around 1150 AM, she did vomit and kept coughing. When I saw her at the bedside, she was unresponsive and very congested breathing was noted. The gown was soaked with gastric emesis. Initial VS, bp120/42, HR 88, O2sat 88%w/ RA, RR 40 and BG 194. No IM Lasix at this facility per nurse. Stat cxr, CBC, BNP, CMP, NH3 and oral suction and breathing tx and full o2 application. Unfortunately, oral suction was malfunctioning. Breathing tx was given but her o2 sat was down to 60%. it was not successful. Apply NRB with 15L and went up to 82%. bp 112/ 52, hr 68, rr 50, o2 sat 67% with NRB 15 L. Worsening hemodynamic status and still unresponsive. at 1200 PM, called 911 for the sudden neuro change, suspected aspiration related respiratory failure and possible ET for airway protection. Notified Dr. about the change in condition and agreed with the hospital transport for the higher level of care. 911 arrived and took her to the hospital around 12 15 pm without ET, o2sat 81%w/ NRB and no status changed . Record review of CR#1's EMS records dated 5/8/24 revealed read in part: .Primary Symptom: Neuro Unconscious/Unresponsive Began: 05/08/2024 12:00:00 Location: General/Global Activity: General Seated or Lying Down, Not Sleeping Possible Injury: No Cardiac Arrest: No Narrative: m050 was dispatched to a possible cardiac arrest. M050 aostf a 57 yo female with a cc of unconscious/unresponsive. the pt was found laying semi-Fowler on hospital bed inside of a nursing home. Staff was not present to give a report. It is unknown the pt baseline and when the pt was last seen normal. The pt was being ventilated with a bvm and o2 by e005. The pt had vomit coming from her nose and mouth. The pt was suctioned on scene. The pt was moved to the back of the ambulance. An igel size 4 and end tidal were established. The pt was hyperventilated do to a low o2 sat. The pads were placed on the pt. IV access was obtained. The pt was administered a normal saline bolus. The pt vitals were monitored enroute to the er. The pt bp dropped below 90 systolic. Nor epi was administered while enroute to the er. The pt was suctioned throughout transport. The pt vitals were monitored. The pt bp improved and vitals remained stable. Nor epi was discontinued pmhx as listed. nkda. The pt had a gcs of 3, pupils PERRL, lungs clear and equal, skin warm and dry. 12:29:42 HR 62 O2 Sat 18% , 12:33:19 HR 80 BP 73 / 32 HR 15 O2 Sat 75% . Record review of CR#1's Emergency Department records dated 5/8/24 revealed read in part: .Procedure-Endotracheal intubation. Time: 05/08/2024 13:05. Confirmed: Patient, procedure, and site correct, Time-out taken prior to procedure. Indication: Airway protection. - The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life-threatening deterioration in the patient's condition during their evaluation in the ED . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676258 If continuation sheet Page 2 of 9 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 676258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of CR#1's Neurocritical Care Note dated 5/8/24 revealed read in part: .Chief Complaint 05/08/2024 12:50 Pt came from by EMS, unknown hx, unknown baseline. Found unresponsive, hypotensive at seen with BP of 50/30, started on levophed and 300ml NSS by EMS, ambu-bagged on way here. History of Present Illness 57yoF w/ PMHx prior stroke, stercoral colitis s/p colostomy, chronic paraplegia, wheelchair bound, DVT on Eliquis (unknown medication compliance), and bipolar disorder, is BIBEMS from after she was found unresponsive. Unknown last seen normal. Patient was reportedly GCS 3, and there was no staff available to provide additional history. EMS intubated the patient for airway protection and started a norepi drip when she was found to be hypoxic and hypotensive. Per EMS, patient had a copious amount of dark green mucus in the nose and mouth. CTA shows no intracranial flow. Patient is admitted to for close neuromonitoring and further evaluation with possible progression to brain death . Record review of CR#1's hospital discharge summary revealed read in part: .Date of admission: Patient was admitted on [DATE]. Date of discharge: Time of death 20:28 on 05/11/2024. All Diagnoses This Visit: Altered mental status, Anoxic brain injury, Coma Diffuse cerebral edema, other shock, Respiratory arrest. Hospital Course: 57yoF w/ PMHx prior stroke, stercoral colitis s/p colostomy, chronic paraplegia, wheelchair bound, DVT on Eliquis (unknown medication compliance), and bipolar disorder, is BIBEMS from after she was found unresponsive. Unknown last seen normal. Patient was reportedly GCS 3, and there was no staff available to provide additional history. EMS intubated the patient for airway protection and started a norepi drip when she was found to be hypoxic and hypotensive. Per EMS, patient had a copious amount of dark green mucus in the nose and mouth. CTA shows no intracranial flow. Patient is admitted to for close neuromonitoring and further evaluation with possible progression to brain death. Over the course of her hospitalization patient was declared brain dead (20:28 on 05/11/2024) by way of cerebral blood flow test. Guardian was contacted and funeral arrangements were made. Patient was taken off of artificial support on 5/13/24 and transported to the funeral home . In a telephone interview on 5/10/24 at 9:56a.m., with the Hospital Case Manager, she said CR#1 arrived from the nursing facility intubated and unresponsive. CR#1 was determined to be brain dead. She said per EMS CR#1's 02 was 18%. When the hospital nurse called the nursing home to get a report from the facility, she said there was no answer. She said the hospital had received many pts from that facility in poor condition. She said the facility's Administrator was contacted. The Administrator said it was clinical and asked ADON A to give report. ADON A said the NP was in the room at that time. Hospital Case Manager said she requested NP's number as the doctor had questions. In an interview on 5/10/24 at 1:13p.m., with LVN B, she said she had not worked with CR#1. She said she worked PRN at this facility, and this was her first day on the floor. When asked in the event of an emergency where would she get the oral suctioning machine from. LVN B said the oral suctioning machine should be at bedside if there was an order. I don't know where the machine is kept. But it's a good question I will definitely ask. In a telephone interview on 5/10/24 at 1:27p.m., with LVN A, she said when she made her morning round CR#1 was alert, oriented, and talking. CR#1 ate breakfast and took her morning meds. LVN A said she was passing meds when she heard coughing and a gurgling noise. She said she entered CR #1's room and observed CR#1 slumped over. She said when she called CR#1's name, the resident was not responding. She said she checked vitals and her O2 was in the 80s, but the resident was still not responding. She said she called the Unit Manager to assess. The NP was in the facility, and the NP assessed CR#1. Resident O2 Sat were low, non-rebreather was applied. The NP gave the order to send the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676258 If continuation sheet Page 3 of 9 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 676258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055 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 out 911 to the hospital. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 5/10/24 at 1:40p.m., with RN Care Coordinator, she said CR#1 was fairly new to their case load. CR#1started their services in January 2024. She said CR#1was seen by the NP twice a week and once a week by the doctor. She said CR#1 was seen by the NP when CR#1 was transferred to the hospital. She said O2 sat less than 92% required oxygen via nasal cannula and non-rebreather mask was used to deliver high percentage of oxygen. Residents Affected - Few Record review and interview on 5/10/24 at 1:48p.m., with the DON, ADON A, and ADON B. The DON said CR#1 was still breathing when CR#1 left the facility. ADON A said they were in a meeting when the nurse said CR#1 had a change of condition. On the way to assess the resident, the NP was met on the hallway and was asked to assess CR#1. The NP asked for Lasix IM and was told the facility did not have it. The NP ordered oral suctioning and a breathing treatment. After the treatment the O2 was in low 80s so they changed to nonrebreather mask and watched for a few minutes. ADON A said when she suctioned there were clear liquids, and nothing came out. The NP checked CR#1's eyes for neurological changes with the pen light. They called 911 and the EMS came within 10-15 minutes. She said the nurse and the NP were in the room with CR#1 while they gathered paperwork. ADON A said the oral suctioning machine was used. She said she connected the tubing to the suction machine and not the nurse so I know the suction machine was working. This State Surveyor asked to see the suction machine used on CR#1. ADON A said the machine was in the central supply to be decontaminated. The DON said the Respiratory Therapist checked the equipment once a month and as needed when visiting the facility as the facility did not have trach/vents. The DON said if the machine malfunctioned, the Respiratory Therapist would label it to be fixed. The State Surveyor reviewed the NP's note in which the NP documented oral suction was malfunctioning. ADON A said the NP was in and out of the room and on her phone most of the time don't know why she documented that. ADON A said CR#1 sats were in low 80s. She suggested to the NP to send CR#1 to the hospital. NP wanted to order stat x-rays and labs. ADON A said 911 wound not have taken CR#1 if she was not breathing. In a telephone interview on 5/10/24 at 2:16 p.m., the NP said the nurse called her to see CR#1 for sudden change in condition. Around 11:50 AM, CR#1 vomited and kept coughing. She said she saw CR#1 at the bedside. CR#1 was unresponsive and very congested breathing was noted. CR#1 gown was soaked with gastric emesis. There was no IM Lasix at this facility per nurse. She ordered oral suction, breathing treatment, and O2. Breathing tx was given but her O2 sat was down to 60%. It was not successful. Applied NRB with 15L and went up to 82%. CR#1 was still unresponsive. The NP said she documented, Unfortunately; oral suction was malfunctioning in her progress notes because she worked at the hospital and had not seen this suctioning machine before. She said there was clear liquid, no food when suctioning so she assumed the machine was malfunctioning. She said the staff brought 2nd suctioning machine and there was clear liquid. She said she called the Doctor and at 12:00 PM, the EMS was called for the sudden neuro change, suspected aspiration related respiratory failure and possible ET for airway protection. She said brain cells were very sensitive to a lack of oxygen. She said brain cells start dying less than 5 to 10 minutes after their oxygen supply disappears. In an interview on 5/10/24 at 2:50p.m., Hospital RN said CR#1's admitting diagnosis was anoxic brain injury, coma, and respiratory arrest. In an interview on 5/10/24 at 3:03p.m., Neurosurgery Doctor said CR#1 was found unresponsive and there was evidence that CR#1 had not gotten oxygen for 30 plus minutes as there was no blood flow to the brain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676258 If continuation sheet Page 4 of 9 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 676258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on 5/19/24 at 10:01a.m., with the DON, she said the facility had Lasix in the Ekit. The DON said nurses were reeducated on the contents of Ekit, to include a vial of Lasix and the procedure for updating the pharmacy for Ekit use. In an interview on 5/19/24 at 10:13a.m., with LVN A, she said one oral suctioning machine was used on CR#1. She said the machine was brought in the room by somebody there were too many people in the room she could not recall who brought the machine. She said she did not see who connected the tubing on the machine. LVN A said, I suctioned her I was the closest one to her. There was only clear liquid. She said the NP was in and out of the room at that time. She said nurses were responsible for sanitizing the used machine and to place it back in the storage room. She said she had not seen a Respiratory therapist in the facility as there were no trach/vent residents. In an interview on 5/19/24 at 10:33a.m., with CNA BB, she said CR#1 required extensive/total care with all ADLs. She said CR#1 was talking and ate her breakfast that morning. She said she went to take the food cart to the kitchen. It was matter of minutes resident had change of condition. When she returned to the hall the nurses were in the room with CR#1. In a telephone interview on 5/20/24 at 1:03p.m., with CR#1's Doctor. The Doctor said CR#1 had a change of condition and they started interventions. They checked BP, HR, and O2. Her O2 sat was low so the oxygen was given. Her O2 did not increase so the non-rebreather was applied. Pt was a full code and intended ET. Her BP was fluctuating on lower levels, unresponsive, and she did not respond well to oxygen so 911 was triggered. She said if the pt was full code, unresponsive, checked vitals, and had no pulse. CPR and 911 should be initiated. She said 911 would come in 8-10 minutes. She said if pt had BP staff should do interventions to keep pt stable until 911 arrives. Record review of facility's Abuse, Neglect, and Exploitation policy (Date Implemented: 8/15/22) revealed read in part: . Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Policy on Respiratory distress was requested along with Abuse/neglect policy. No policy on respiratory distress was provided on exit. This was determined to be an Immediate Jeopardy (IJ) on 05/18/2024 at 1:11pm. The facility's Administrator, the DON, and the Regional Clinical Specialist (on phone) were notified. The Administrator was provided with the IJ template on 5/18/24 at 10:55am. The following POR submitted by the facility was accepted on 5/18/24 at 7:41pm. The POR read in part: . LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On May 18, 2024, the facility was notified by the state surveyor, that an immediate jeopardy had been called and the facility needed to submit a Plan of Removal pursuant to Federal and State (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676258 If continuation sheet Page 5 of 9 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 676258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055 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 regulatory requirements. The immediate jeopardy allegations are as follows: Level of Harm - Immediate jeopardy to resident health or safety F- Tag 600: Free from Abuse and Neglect. Facility failed to provide prompt care to CR#l when she experienced respiratory distress in the presence of the NP. Residents Affected - Few Done for those affected: Resident CR#l is no longer in the center. Identify residents who could be affected: o Beginning 5/18/24, head to toe assessments were completed by Licensed Nurses on all residents to identify any signs of change in condition. Concerns will be reported to the MD/NP. By 5/ 18/2024 o Beginning 5/18/24, the DON/ designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect and changes of condition were identified and an investigation initiated, and physicians were notified with no concerns noted. By 5/18/2024. The facility's policy and procedure related to Abuse and Neglect prohibition was reviewed with no concerns and/or updates indicated. By 5/18/2024 Systemic Process: . On 5/18/24, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and the Director of Nursing on Abuse and Neglect Policy to include providing prompt care to residents experiencing change in condition. By 5/ 18/2024 o On 5/18/24, the Administrator/ the DON and/ or designee began reeducation to 100% of the facility staff on the following: By 5/18/2024 o Abuse and Neglect Policy to include reporting and providing prompt care when a resident has a change in condition. o On 5/18/24, the DON and/ or designee began reeducation to 100% of Licensed Nurses on the following: By 5/18/2024 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676258 If continuation sheet Page 6 of 9 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 676258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055 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 o Level of Harm - Immediate jeopardy to resident health or safety Calling report to the ER when transferring resident to the ER Residents Affected - Few Contents of [NAME].it , to include vial of Lasix and procedure for updating pharmacy of ekit use. o o Documentation in the medical record of actions taken when a resident experiences a change in condition o Use of suction machine o Staying with a resident when 911 has been activated o Effective 5/18/24, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, the DON and/or designee prior to the start of their next scheduled shift. o The Director of Nursing/ designee will review the 24-hour report for any changes in condition. Ensure that physician is notified timely and that actions are taken timely to address the change in condition. By 5/18/2024 Monitoring: An Ad Hoc QAPI was conducted on 5/18/24, attended by the Administrator, the DON, the Medical Director, and the Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 600-Free From Abuse and Neglect. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 5/18/24 . The surveyor confirmed the facility implemented their plan of removal and Monitoring began on 5/19/2024. In an interview on 5/19/24 at 9:45a.m., with the Administrator and the DON, the Administrator said he was the abuse coordinator he was reeducated by the Regional Clinical Specialist on the Abuse policy. He said he then reeducated all staff on the Abuse and Neglect Policy to include reporting and providing prompt care when a resident has a change in condition. The DON said she reeducated nurses on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676258 If continuation sheet Page 7 of 9 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 676258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few calling report to the ER when transferring resident to the ER. Contents of Ekit, to include vial of Lasix. Documentation in the medical record of actions taken when a resident experiences a change in condition. Use of suction machine with return demonstration by nurses. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the [NAME] Clinical Specialist to the Administrator and the Director of Nursing. Topic: Abuse and Neglect Exploitation/ Prompt Care in the Event of Change in Condition. Contents or summary of training session: the Administrator and the DON were reeducated on the facility's abuse and neglect exploitation policy. Reeducation included examples of abuse and neglect; who was at risk and why. Reeducation also included the need for prompt intervention in the event of a change in condition. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the DON to all staff. Topic: Reporting Changes in Condition/ Communication with Charge Nurse/ MD/ NP RP/ Follow up Notification. Contents or summary of training session: Attendees were reeducated on identifying and reporting resident changes in condition and who to report changes to. Examples of changes to observe for reviewed e.g. bruises, skin tears, cough, new complaints of pain, runny nose, increased confusion, diarrhea, abnormal vital signs, odors in urine, bleeding of any kind, and any condition not normal for the resident. Immediate reporting emphasized. Staff also instructed to continue to report observations even if he/she believes it has been reported; as well as notifying the DON/ ADON and if applicable the Administrator of Changes in Condition which are identified and not addressed timely to include after-hours weekendsand holidays. Licensed Nurses reeducated on documentation, MD/NP/RP notification, and change of condition follow-up. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the Administrator to all staff. Topic: Abuse and Neglect Exploitation/ Prompt Care in the Event of Change in Condition. Contents or summary of training session: Staff were reeducated on the facility's abuse and neglect exploitation policy. Reeducation included examples of abuse and neglect; who was at risk and why. Reeducation also included the need for prompt intervention in the event of a change in condition. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the DON to Licensed Nurses (RN and LVN). Topic: Change in Condition/ Communication with MD/NP/RP and Documentation. Contents or summary of training session: Licensed Nurses were reeducated on identifying and reporting resident changes in condition. Examples of changes reviewed e.g. bruises, skin tears, cough, new complaints of pain, runny nose, increased confusion, diarrhea, abnormal vital signs, bleeding, odors in urine, and conditions reported by residents, staff, and/ or families. The Charge Nurses were reeducated on assessment of residents with reported and identified changes in condition to include head to toe assessment, completion of vital signs, and any other pertinent assessment, as well as completion of the Change in Condition Form and PROMPT communication with the MD/NP with assessment findings. Charge nurses reeducated on following any orders obtained related to change in condition, writing applicable progress notes, with time frames, and monitoring outcomes and communicating them timely with the MD/RP and as necessary with on-coming nurse. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the DON to Licensed Nurses (RN and LVN). Topic: Emergency Procedures and Communication. Contents or summary of training session: Licensed Nurses were reeducated on the procedure for monitoring and communication in the event of a medical emergency/ resident change in condition. Licensed Nurses reeducated on ensuring someone remains with the resident and resident was montiored throughout. Monitoring and interventions should be documented in the medical record and staff should remain with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676258 If continuation sheet Page 8 of 9 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 676258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident until EMS/ 911 arrival. Licensed Nurses must call report to the receiving hospital to include details of the resident condition and document communication with hospital staff in the medical record. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the DON to Licensed Nurses (RN and LVN). Topic: Oral Suctioning, Checking of Suction Machine for function, Ekit Contents, and updating pharmacy on use. Contents or summary of training session: Licensed Nurses were reeducated on oral suctioning with return demonstration. Reeducation also included how to check suction machines for function, documentation on crash cart check list, and how to validate suction machine function at onset of use with return demonstration on oral suctioning). Licensed Nurses were reeducated on the facility ekits and contents (Cubex, IV, Refrigerator). Reeducation included location of ekits, use of ekits, and pharmacy refill process and notification in the event medication was needed to be refilled. Observed head to toe assessments were completed by Licensed Nurses on all residents to identify any signs of change in condition. No concerns were identified. Observed the DON reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect and changes of condition were identified and an investigation initiated, and physicians were notified with no concerns noted. During the monitoring phase, interviews were conducted by the state surveyor with various staff on different shifts (Administrator, DON, [NAME] Clinical Specialist, 9 LVNs, 3 CNAs and 4 Medication Aides). Staff interviewed indicated they had received above mentioned training. No concerns noted. The Administrator was informed that the Immediate Jeopardy was removed on 5/19/24 at 11:13am. The facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676258 If continuation sheet Page 9 of 9