Health inspection·April 3, 2024

F 0584 01, which meant she was dependent- Helper does all the effort. Section H0300- Urinary Incontinence was coded as 2, which meant frequently incontinent. Level of Harm - Minimal harm or potential for actual harm Observations on 4/3/2024: Residents Affected - Some 11:27 a.m.- Resident #1's shower had dried fecal matter on the floor and wall of her shower. 2:11pm - Resident #1's shower had dried fecal matter on the floor and wall of her shower and urine odor. Resident #2 Record review of Resident #2's undated face sheet revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of Malignant neoplasm of connective tissue of right lower limb including hip (cancer), abnormality of gait and mobility (weakness of the hip and lower extremities commonly cause gait disturbance). Record review of Resident #2's care plan revealed: Focus- I have an ADL Self-care deficit r/t foot surgery, pain and bone cancer. Record review of Resident #2's MDS dated [DATE] revealed section C0500- Brief Interview of Mental status coded as 15. Section GG Functional Abilities - P. Picking up objects (the ability to bend/stoop from a standing position to pick up small objects was coded as 9 for not applicable(activity not attempted). Observation of Resident #2's room on 4/3/2024 at 2:37pm revealed Resident #2 had a bag of clothes and shoes that cluttered her floor. An interview with Resident #2 at 2:37pm revealed she had been admitted about one month ago. She said she was no longer capable of housework. She said she had mentioned that the bag of clothes and shoes needed to be placed in her closet, but she did not recall the CNA's name. Resident #3 Record review of Resident #3's face sheet revealed he was an [AGE] year-old that was admitted to the facility on [DATE] with diagnoses of acute cerebrovascular insufficiency (obstruction of one of more arteries that supply blood to the brain), cognitive communication deficit (difficulty with thinking and how someone uses language), sepsis(a life-threatening complication of an infection) and acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues). Record review of Resident #3's care plan dated 4/1/2024 revealed: Focus- I have a communication problem r/t/cognitive impairment. Intervention: Anticipate and meet needs and bladder incontinence revealed he should be checked throughout the shift for incontinence. Observations on 4/3/2024: -10:22am- Resident #3's room had a strong urine odor. He was not in the room at the time. -1:37pm- Resident #3's room had a strong urine odor. He was asleep. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676306 If continuation sheet Page 2 of 6 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 676306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holly Hall 2000 Holly Hall St Houston, TX 77054 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 0584 Level of Harm - Minimal harm or potential for actual harm An interview with Resident #1's RP on 4/3/24 at 12:47pm, Resident (RP) revealed she observed feces on Resident #1's shower walls and floor about two days ago. She said briefs have been observed on the floor of the bathroom as well. She said she was told the CNAs were responsible for changing her briefs and showering her. She said they should have cleaned the shower after showering her. She said the facility had mostly agency staff that were not doing a good job. Residents Affected - Some An interview with LVN A on 4/3/2024 at 2:44pm, she stated she is an agency nurse. She said it is the responsibility of CNAs to rinse showers, change adult briefs and organize the residents' personal clothing and shoes. She said she was not sure why these tasks were not done. She said two CNAs were working on each hall. An interview with CNA A on 4/3/2024 at 3:08pm, revealed she had been employed at the facility for 12 years. She said CNAs are responsible for 3-4 showers per day and after showering residents they are supposed to rinse the shower. Observation rounds and interview with the DON on 4/3/2024 at 3:26pm, revealed Resident #1 had fecal matter on her shower and wall, Resident #2 did have clothes and shoes which cluttered her floor and Resident #3's room had a urine odor. She said it is both the nurses and CNA's responsibility to ensure all resident showers are clean, no odors and they are responsible for organizing residents' clothing in their closets. She said this was only her second day in this position and she would work with staff to fix these issues. She said having unclean and unsanitary rooms could affect residents' dignity. An interview with the Administrator on 4/3/2024 at 4:06pm, he said he has been employed at the facility for about 2 months and the odors and fecal matter in the residents' showers would be addressed with an in-service because this does not comply with the facility standards. Record review of resident rights policy Section 2 stated residents are entitled to their rights and privileges to have a clean comfortable environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676306 If continuation sheet Page 3 of 6 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 676306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holly Hall 2000 Holly Hall St Houston, TX 77054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to ensure a resident that was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 4 (Resident #1 and Resident #3) reviewed for Activities of Daily Living. Residents Affected - Some 1. The facility failed to ensure Resident #1's adult brief was checked and changed as needed. 2. The facility failed to ensure Resident #3 was given scheduled showers. This failure could affect all dependent residents that required staff assistance with activities of daily living and could result in poor hygiene and skin breakdown. Findings Included: Resident #1 Record review of Resident #1's undated face sheet revealed she was a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses of Heart failure (a chronic condition in which the heart does not pump blood as well as it should), Alzheimer's Disease (a disease that destroys memory), Type 2 Diabetes (a long-term condition in which the body has trouble controlling blood sugar) and Essential hypertension (high blood pressure). Record review of Resident#1's care plan dated 3/28/2024 revealed: Focus-I have an ADL self-care performance deficit, poor endurance, poor memory, and safety awareness. Intervention-Bathing Require 1 person staff participation to use toilet and 1 person staff participation with transfers. requires 1 person staff participation with bathing. Record review of Resident #1's MDS dated [DATE] revealed Section C0500 Brief Interview of Mental Status was coded as 12. Section GG- Functional Abilities and Goals #C toileting hygiene was coded as 01, which meant she was dependent- Helper does all the effort. Section H0300- Urinary Incontinence was coded as 2, which meant frequently incontinent. Observations of Resident #1 -11:25am revealed she had just arrived from a doctor's appointment on a stretcher. She was transferred to her chair. -12:42 pm, Resident was observed to be sitting in her chair with leftover lunch in front of her. She had a urine smell. - 2:11pm, Resident raised her dress to show a brief that was filled with urine after she was asked if her brief was wet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676306 If continuation sheet Page 4 of 6 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 676306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holly Hall 2000 Holly Hall St Houston, TX 77054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm An interview with Resident #1's RP on 4/3/24 at 12:47pm, Resident (RP) said she was told the CNA's were responsible for changing her briefs and showering her. She said she is constantly wet when she or other family members have visited with her. She said she has raised these concerns with the ADON and have not seen a change. Residents Affected - Some Resident #3 Record review of Resident #3's undated face sheet revealed he was an [AGE] year-old that was admitted to the facility on [DATE] with diagnoses of acute cerebrovascular insufficiency (obstruction of one of more arteries that supply blood to the brain), cognitive communication deficit (difficulty with thinking and how someone uses language), sepsis(a life-threatening complication of an infection) and acute respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues). Record review of MDS dated [DATE] revealed Section C0500- Brief Interview of mental status score was 0, which represented severe cognitive impairment. Section GG0115- revealed upper and lower extremity impairment. Section GG 0130- Functional abilities and goals C. Toileting hygiene was coded as 01- which meant dependent- helper does all of the effort. E. Shower/bathe self was coded as 01 which meant dependent- helper does all of the effort. Section H0300- Urinary incontinence coded as 3-always incontinent. Record review of Resident #3's care plan dated 4/1/2024 revealed: Focus- I have a communication problem r/t/cognitive impairment. Intervention: Anticipate and meet needs and bladder incontinence revealed he should be checked throughout the shift for incontinence. Observations on 4/3/2024: -10:22am- Resident #3's room had a strong urine odor. He was not in the room at the time. -1:37pm- Resident #3's room had a strong urine odor. He was asleep. Record review of Resident #3's shower sheets revealed the following dates were documented in PCC (electronic medical record) as having a shower/bath: 3/15, 3/20, and 3/22/2024 only. There were no other shower sheets found. An interview with LVN A on 4/3/2024 at 2:44pm, she stated she is a contract nurse. She said it is the responsibility of CNA's to shower residents and change adult briefs. She said she was not sure why these tasks were not done. She said two CNAs were working on each hall. An interview with CNA A on 4/3/2024 at 3:08pm, revealed she had been employed at the facility for 12 years. She said CNA's are responsible for 3-4 showers per day. She said they round every 2 hours, and no residents should be left in a soiled diaper. She said CNAs are supposed to provide the shower sheets to the ADON and she believed the ADON would then enter this information into PCC. Observation rounds and interview with the DON on 4/3/2024 at 3:26pm, revealed Resident #1's brief was wet. Resident #3's room had a urine odor. She said it is both the nurses and CNA's responsibility to ensure all residents are showered and briefs are changed as needed or required. She said this was only her second day in this position and she would work with staff to fix these issues. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676306 If continuation sheet Page 5 of 6 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 676306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Holly Hall 2000 Holly Hall St Houston, TX 77054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 residents having wet briefs and not getting showers as needed could cause skin breakdown. Level of Harm - Minimal harm or potential for actual harm An interview with the Administrator on 4/3/2024 at 4:06pm, he said he has been employed at the facility for about 2 months and the odors, briefs not being changed timely as well as the issue with showers as ordered would be addressed in-services because this does not comply with the facility standards. Residents Affected - Some A policy on ADL's was requested but never received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676306 If continuation sheet Page 6 of 6