Inspection·November 18, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Foley catheter tubing and dislodging the Foley catheter. CNA B said she was not assigned to Resident #1 and was just assisting with her care. Interview on 11/13/25 at 5:40 PM, the DON said all residents with Foley catheters should have a leg strap to prevent dislodging the Foley catheter. Record review of the NF policy on Catheter Care, Urinary, revised September 2014, reflected in part: .Ensure that the catheter remains secure with a leg strap to reduce friction and movement at the insertion site. (Note: catheter tubing should be strapped to the resident's inner thigh). 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 11/18/2025 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 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 to provide a safe, sanitary and comfortable environment to help prevent the transmission of communicable diseases and infections for 1 of 8 Residents (Resident # 1) reviewed for infection control. 1. The ADON and CNA B failed to wear full PPE (disposable gown) when providing Foley catheter care for Resident #1. 2. RN A failed to wear full PPE (disposable gown) when performing Resident #1's wound dressing changes to the sacrum (large bone triangular positioned at the very base of the spine) and RL ischium (the bone that supports the upper body's weight and balance that is located near the pelvis [bone at the base of the spine]). These failures could place residents at the risk of acquiring and spreading multidrug-resistant organisms through contact with staff and other residents that could lead to unwanted infections. Findings include: Record review of Resident #1's face sheet, dated 11/13/25, reflected a [AGE] year-old female who was admitted to the facility originally on 11/29/24 and readmitted on [DATE]. Resident #1 had diagnoses which included the following: paraplegia (loss of movement typically in the legs, caused by a spinal injury or another condition), ileus (temporary absence of the intestinal muscle contraction that prevents the normal flow of intestinal contents and cause short term blockage), muscle wasting and atrophy ( shrinking of muscle due to lack of use of the muscle), intraspinal abscess (serious infection where pus builds up cause by a bacteria) and granuloma (forming of cells that forms in a response to long time injury or infection, identified by redness, swelling, heat, pain, and loss of function), osteomyelitis (bone infection)of the vertebra lumbar region (bones of the lower back), type 2 diabetes mellitus (when the body does not produce enough insulin or does not use it properly to keep blood sugar levels normal), and depression. Record review of Resident #1's Comprehensive Care Plan, dated 08/27/25 and revised 09/04/25, reflected Resident #1 was care planned for EBP as evidence by chronic wound-sacrum & RL ischium with interventions that included the following: -Post EBP on the door to room -Provide Protective Equipment at entrance to door. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 13, which indicated the resident's cognition was intact. Record review of Resident #1's Physician Order Summary Report for the month of November 2025 reflected the following orders: -Dated 08/28/25 Foley Catheter 16 F/10 cc bulb -Dated 09/24/25 Wound Treatment to right buttock cleanse with 1/4 Dakins solution, pat dry, apply santyl (medicated ointment used to remove dead tissue from chronic wounds to promote wound healing) and cover with border dressing every day shift. -Dated 10/07/25 Wound Treatment: Sacral stage 4 pressure: cleanse with Dakins (wound cleanser made from diluted household bleach, baking soda, and water use to treat and prevent infections in various wounds) 1/4 strength pat dry and apply NPWT @ 125 mmhg continuous pressure. As needed if dislodge apply Dakins soaked gauze and apply border dressing. Observation on 11/13/25 at 4:11 PM revealed Resident #1 resting in bed on an air mattress awake looking at her cell phone. There was an Enhanced Barrier Precaution on the outside of the resident's door informing the staff to put on gowns and gloves. There was a PPE storage cart outside of resident doorway with PPE inside that consisted of gown and gloves. Resident #1 had an indwelling Foley catheter hanging on the left side of the bed inside of a privacy bag. Observation on 11/13/25 at 4:38 PM revealed RN A, ADON, and CNA B entered Resident #1's room without placing on a disposable gown and washed their hands with soap and water and donned gloves. The ADON and CNA B proceeded to provide Foley catheter care for Resident #1. When the ADON and CNA B were done providing care, RN A began to change Resident #1's dressings to her wounds which consisted of the sacrum and the right lower ischium/buttock area. Observation of the wound bed to the sacrum being red in color, no odor but a Residents Affected - Few (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 11/18/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete small amount of red drainage was observed. RN A cleaned the wound bed with Dakins solution 1/4 strength cleaning the wound bed from the inside out one wipe at a time. When RN A was done cleaning the sacral wound, he packed the sacral wound with a sponge material, covered it with a translucent tape and attached the wound vac tubing in the center of the dressing. RN A proceeded to clean the right ischium/buttock area with the same solution and in the same fashion, pat dry and applied santyl ointment to the wound bed. The wound bed to the right ischium/buttock area was observed with some black discolored areas in the wound bed with a small amount of red drainage. When RN A was done, he discarded all soiled materials inside of a red biohazard bag, washed hands along with the ADON and CNA B. Interview on 11/13/25 at 5:22 PM, the ADON said the reason she did not place on full PPE when assisting with Foley catheter care and wound care for Resident #1 was due to her being distracted. The ADON said she placed Resident #1 at risk for cross contamination. Interview on 11/13/25 at 5:30 PM, RN A said he was supposed to wear a gown when he changed Resident #1's wounds. RN A said he forgot to put on his disposable gown. RN A said this placed the resident and himself at risk for cross contamination. Interview on 11/13/25 at 5:35PM, CNA B said she forgot to put on the disposable gown. CNA B said placing on full PPE was for infection control. Interview on 11/13/25 at 5:40 PM, the DON said the staff should have been wearing full PPE that consisted of disposable gowns and gloves when providing direct care for Resident #1 due to the resident having wounds and a Foley catheter. The DON said these measures were taken to prevent cross contamination and infection control. The DON said she would be in-servicing the staff. Record review of the facility's policy on Infection Control, dated November 2017, reflected in part: .The facility must establish an infection prevention and control program that must include: a system for prevention, identifying, reporting, investigations, and controlling infections and communicable diseases for all patients, staff, volunteers, visitors, and other individuals. Record review of the facility's policy on Enhanced Barrier Precautions, revised March 2024, reflected in part: .Enhanced Barrier Precautions (EBP) is an infection control intervention to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and gloves use during high- contact resident care activities.EBP is indicated for residents with any of the following: chronic wound (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers (open sore on the lower leg, often on the ankle, cause by poor vein function and fluid buildup) and/or indwelling medical devices (.urinary catheter.) even if the resident is not known to be infected or colonized (when germs are present on or in the body without causing illness).with a CDC-targeted MDRO. EBP will be used when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care (central line, urinary catheter, feeding tube, tracheostomy (surgical procedure that creates an opening in the neck to place a tube into the windpipe to help a person breathe), wound care. Event ID: Facility ID: 676323 If continuation sheet Page 4 of 4