Inspection·March 22, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Worker informed Resident #3's FM that Resident #3 did not want Long-Term care. Resident #13's said he will speak with Resident #3. Record review of Resident #3's Expedited Appeal Documentation Request dated 01/30/25, revealed submitted medical records, Notice of Medicare Non-Coverage, Detailed Explanation of Non-Coverage, copy of the beneficiary's medical record from the last seven days, face sheet, wound care orders and flow sheets, skilled nursing notes, ST evaluation and progress notes, OT evaluation and progress notes, PT evaluation and progress notes, physician progress notes, physician orders, and history and physical. Record review of Resident #3's Notice of Medicare Non-Coverage, revealed the effective date coverage of residents skilled nursing facility services would end 02/01/25 signed by Resident #3 on 01/30/25. Record review of Resident #3's progress note dated 02/03/25, revealed the Social Worker scheduled a community liaison to speak with Resident #3 last week. The Social Worker said Resident#3 was provided boarding home options but the resident declined. Record review of Resident #3's Letter of written notice dated, 02/18/25 revealed that the resident received her 30-day written notice attached with another copy of the Notice of Medicare Non-Coverage. Record review of Resident #3's progress note dated 03/04/25, revealed the Social Worker informed the resident she had been denied Long-term care due to being over resourced. Record review of Resident #3's progress note dated 03/05/25, revealed the Social Worker informed the resident she had been denied Long-term care due to being over resource amount. Record review of Resident #3's Psychiatric Subsequent assessment dated [DATE], revealed assessment/plan Generalized anxiety disorder is being treated with Alprazolam 0.5 orally Disintegrating (breaking down into smaller parts or fragments) tablet 0.25mg (milligram) BID (twice a day) PRN (as needed) and Hydroxyzine 1 tablet 25mg (milligram) will continue to use Alprazolam and Hydroxyzine to target sxs (symptoms) of anxiety .will continue with supportive care. Record review of an Invoice #005 dated and issued, 03/18/25 to assist Resident #3's housing fee in the amount of $700.00. The comprehensive care plan and the advance directives provided. Record review of Resident #3's progress note dated 03/18/25, revealed the Social Worker spoke with the resident regarding a discharge update. Resident#3 was discharging to a PCH . Resident #3 said she has already ordered her hospital bed and wheelchair is at her bedside. Record review of Resident #3's progress note dated 03/18/25, revealed the Social Worker called the resident and scheduled a follow-up appointment dated 04/15/25. Record review revealed Resident #3's discharge date d 03/18/25, revealed she went to an assisted living/board and care/group home . During an interview on 3/22/2025 at 10:08 am with the DON, she said once the resident admits in the facility, there were weekly updates the facility sends to the insurance. The DON said when the resident was at their maximum the resident could go to the next level of care. The DON said the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676323 If continuation sheet Page 2 of 4 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 676323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Crescent 11353 Sugar Park Lane Sugar Land, TX 77478 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insurance issues a NONMC (notice of non-medical coverage). The DON said the resident had a right to appeal. The DON said if the resident won the appeal they could remain in the facility. The DON said the resident could continue with their services until another NONMC was received. The DON said if the resident did not appeal the insurance the resident was given 48 hours. The DON said if the resident did not win the appeal it would transfer to private pay. The DON said when the resident did not pay private pay then a 30-day discharge was given to the resident. The DON said the resident was given the NONMC, and the Social Worker could assist if the resident requested assistance (how to appeal the NONMC). The DON said the risk to an unsafe transfer/discharge was the resident returning to the hospital. The DON said the risk was also the resident not getting proper care and which could harm the resident . During an interview on 3/22/2025 at 12:38 pm with LVN A, she said she had been working with Resident #3 every weekend since she has been admitted into the facility. LVN A said Resident#3 was a pleasant person to her. LVN A said she knew Resident#3 had an amputee on her right leg. LVN A said Resident #3 was very outspoken and she would tell you what she needed. LVN A said Resident #3 never took showers, she has always taken bed baths on Saturdays. LVN A said Resident#3 never complained. LVN A said Resident #3 provided her with the address by showing her a flyer and wanted LVN A to visit. LVN A said the resident said she was going to leave the facility and go to her new place. LVN A said she took a picture of the flyer with her cellphone to assure Resident #3 she would visit her at her new place. LVN A said Resident #3 did not seem sad. LVN A said Resident#3 was packing on the day she was talking to her. During a telephone interview on 3/22/2025 at 1:14 pm with Resident #3, she said she was waiting to receive all her boxes from the home. Resident#3 said she wanted to get back on low subsidy. Resident#3 said she moved again into a brand-new house in {another city name}. During a telephone interview on 3/22/2025 at 3:01 pm the Business Manager said the process for Transfer/Discharge was: She received a fax of the NONMC, she issued it to the patient/resident if they were their own RP, she issued the NONMC to the RP/family, she showed the resident the last service date on the NONMC, she showed the resident the discharge date , she informed the resident of the appeal they could start, she said she informed the residents they had until 12 noon the following date to make the appeal, she checked with the residents the same day to see if they were going to appeal again, she said once the appeal request came through via fax, she said medical records got their records together for the appeal process, she said she waited for the decision by fax, she said she called the patient about the decisions, she said the discharge paperwork was handled by the Social Worker, she said the Social Worker followed up with the resident, she said they prepared the resident for everything (medication, items needed for care etc.), she said she checked out with the nurse, she said she made sure the resident had more than enough medication on hand, she said she made sure the discharge information was correct. She said she forgot the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. She said she had no idea the ombudsman was to be notified and sent a copy of the information. She said the risk to the resident was the resident receiving an unsafe transfer and an unsafe discharge . During an interview on 3/22/2025 at 3:59 pm with the Executive Director (ED), he said he had been working at the facility since 10/28/24. The ED said pertaining to the Transfer/Discharge he would make sure the ombudsman was notified and have the information sent via email. The ED said once the Business Manager and the Social Worker returned to work, as well as the person that handled medical records, he would make sure staff were trained and in-serviced on the proper process of Transfer/Discharge pertaining to the policy and the CMS revised Regulations. The ED said he would talk about the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676323 If continuation sheet Page 3 of 4 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 676323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Crescent 11353 Sugar Park Lane Sugar Land, TX 77478 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete transfer/discharge daily. The ED said he would perform audits to ensure compliance. The ED said the risk to the resident not having a safe transfer/ discharge was having an unsafe discharge, he said the resident could return to the hospital due to an adverse effect. Record review of the policy, Transfer or Discharge Notice dated 12/2016 revealed the following:1. A resident, and /or her representative (sponsor) will be given a thirty (30)-day advance notice of an impending transfer or discharge from the facility .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. Event ID: Facility ID: 676323 If continuation sheet Page 4 of 4