Inspection·January 29, 2024

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Problem: Resident #2 has nutritional problem or potential nutritional problem r/t NPO, g-tube use. At risk for nutritional problem related to DM, hypotension, dysphagia, hyperlipidemia, anxiety insomnia, MDD and hypothyroidism, peg tube status. Goal: Resident #2 will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx of malnutrition, and tolerating tube feeds daily through review date. Intervention: Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide and serve diet as ordered. RD to evaluate and make diet change recommendations PRN. Resident #2 requires tube feeding r/t Dysphagia. Resident #2 will maintain adequate nutritional and hydration status, weight stable, no s/sx of malnutrition or dehydration through the review date. Check for tube placement and gastric contents/residual volume per facility protocol and record. Monitor/document/report to MD PRN: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubating, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. Provide local care to G-Tube site as ordered and monitor for s/sx of infection. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding/flush orders. Observation on 1/24/2024 at 2:00pm revealed Resident#2 in bed with the head of the bed elevated. Feeding pump was infusing at 70ml per hour and water flush at 30ml per hour, and on the bag was written from 10:00pm-6:00am. Further observation revealed the feeding bag had approximately 100 ml of feeding in it. In an interview and observation with LVN B on 1/24/2024 at 2:05pm he said resident was on continuous feed from 10:00pm to 6:00am. He said the feeding should only run on the night shift because the resident was fed by mouth during the day. He said the pump should be off at 6:00am but did not get turned off because he was late coming to work. He said he should have turned the pump off when he got to work but he got busy. At that point he turned the pump off. He was then asked what could happen if the pump was not turned off as ordered. He said that could cause the resident not to eat as much as he normally would eat, because he would be too full, and that could cause him to throw up. In an interview on 1/24/2024 at 2:30pm LVN C said she was not aware that Resident #2's feeding pump was not turned off. She said usually if the nurse was not in, she would try and check all resident to ensure that they were provided the care and services needed until a nurse comes in. She said the nurse came in latee but she thought he had taken care of the resident. In an interview on 1/24/2024 at 2:45pm CNA C said Resident #2 was fed via a feeding tube a night but eats during the day. She said it depends on what was served for the meal, he would eat all his meal and sometimes he would eat a little. She said if he eats less than 50%, they should give him supplement. She said he ate about 50% of his meal that day. In an interview on 1/24/2024 at 3:00pm the DON said that a staff coming to work late should not prevent residents from getting the care and services they required. She said another nurse should have turned the pump off. At that point she said she will have to in-service the staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 2 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's nurse progress notes dated 1/24/2024 revealed no documentation the Resident#2's feeding tube was not turned off at 6:00am as scheduled. CR#1 Record review of CR #1 face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. CR#1's diagnoses included the following: hypertension (high blood pressure), severe protein calorie malnutrition (lack of protein and calories to meet nutritional need), atrial fibrillation (rapid heartbeat that causes poor blood flow), depression (a medical illness that effect the mood), anemia (condition where the blood does not have sufficient red blood cells( dementia (memory loss), acute cerebrovascular insufficiency (condition that affects the blood flow to the brain), gastrostomy (a surgical procedure where a tube is inserted in the stomach for feeding), chronic kidney disease (the inability of the kidney to filter waste and excess fluid from the blood), type 2 diabetes (high blood sugar, epilepsy ( is a brain disorder that causes recurring unprovoked seizures). Insomnia (difficulty falling asleep). Record review of CR#1's MDS dated [DATE] revealed the resident was coded for Cognitive Skills for Decision Making as severely impaired, indicating that CR#1 was not able to make sound decision. She was coded as total care for ADL's incontinent of bowel and bladder and was fed via a feeding tube. Record review of CR#1's care plan revealed the resident was fed via a feeding tube due to dysphagia. CR#1 will be free from aspiration. In an interview on 01/23/2024 at 2:15pm with CNA G she said she provided care to CR#1 on 1/15/2024. She was asked who turned the feeding pump off when care was provided to residents with a feeding tube. She said, if the nurse was not available, she would turn the pump off and on. When asked if she had permission to turn the pump off and on, CNA G did not answer. Observation on 1/24/2024 at 3:00pm of the motion camera footage (a camera that only records when it detects motion in the field of vision) dated 1/15/2024 at 7:15 am revealed CR#1 was in bed with the head of the bed elevated, her left hand was resting on her stomach. Observation revealed the resident vomited up large amount of brown liquid emesis all over her neck stomach and running down her left hand. Further observation revealed the CR#1 was lying in her vomit and no one checked on her every two hours as per facility policy. Observation of the camera footage dated 1/15/2024 at 11:15 am four hours later a CNA that was later identified as CNA H went in the room to check on CR#1. She pulled back the covers and muttered something and left the room. She lLater returned with three aides who were later identified as CNA G, CNA J and CNA K. Further observation revealed CNA H and G removed the covers and started providing care to CR#1, while CNA J stood, a little way from the resident and CNA J who brought some linen put it on the table and stood near the doorway. No one was observed turning the feeding pump off. CNA G and H did not call the nurse to turn the pump off. They provided care to the resident and left the room. Further observation revealed no evidence that the nurse entered the room during and after the care. Interview on 1/27/2024 at 1:15 pm with CNA G after she viewed the camera footage dated 1/15/2024 she had a look of shock on her face. Asked if she was the CNA on the camera she said yes. At that point she was asked if the nurse was called to turn the feeding pump off, she said No. Asked if the pump was off, she said No. She was then asked at that point if she had reported the incident to the nurse, she said no. Asked if the nurse should be called, she said yes. Asked why the nurse was not called she said the nurse was not around. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 3 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 1/27/2024 at 1:30 pm with LVN B after viewing the camera footage he said that was a lot of vomit from CR#1. He said he did not smell any vomit and if he had seen the vomit on her he would have cleaned her up. He reviewed the tape and agreed it was a lot of vomit but still insisted he did not see or smell any vomit. He said he gave CR#1 her medication around 9:00am and he assessed the resident and did not see any change in her condition. He said he was not called when the CNAs were providing care. Further interview with LVN B revealed that when he gives medications to residents who were fed via feeding tubes he usually checked for placement, residual, ensuring that the head of the bed was elevated, and resident was not at risk for aspiration. He said at the end of his shift the resident looked okay. Review of the facility's Enteral Feeding policy, revised January 2014, reflected: Documentation 1. The date and time the procedure was performed. Review of the facility's Enteral Feeding policy, revised May 2014, reflected: Preventing Aspiration: 1.Check enteral tube placement prior to each feeding and administration of medication. 2. Always elevate the head of the bed(HOB) at least 30 degrees-45 degrees during the feeding and at least one hour after. 3. Monitor the tube for resigns and symptoms of respiratory distress during feeding and medication administration. 5. Recognize risk factor for aspiration including. a. sedation, d vomiting, c. bolus feeding, FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 4 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 residents (CR#1) reviewed for quality of care. Residents Affected - Few The facility failed to ensure LVN B properly assess CR#1 when he gave medication on [DATE] at 9:00am when CR#1 vomited, aspirated and later died. The facility failed to ensure that CR#1 was checked on every two hours and was not laying in her vomit from 7:15 am until 11:15am on [DATE]. The facility failed to ensure that CNAs report to the charge nurse when they found CR#1 in her own vomit. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE] at 1:18pm, the facility remained out of compliance at a scope of Level 2 (E) Although there was IJ for one person, the potential for more than minimal harm is a pattern due to the number of staff involved, the facility continued to monitor the implementation and effectiveness of their corrective systems. These failures could place residents who are fed via feeding tube at risk for delayed treatment that could lead to severe injury, aspiration and/or death. Findings Included: CR#1 Record review of CR #1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. CR#1's diagnoses included hypertension (high blood pressure), severe protein calorie malnutrition (lack of protein and calories to meet nutritional need), atrial fibrillation (rapid heartbeat that causes poor blood flow), depression (a medical illness that effect the mood), anemia (condition where the blood does not have sufficient red blood cells( dementia (memory loss), acute cerebrovascular insufficiency (condition that affects the blood flow to the brain), gastrostomy (a surgical procedure where a tube is inserted in the stomach for feeding), chronic kidney disease (the inability of the kidney to filter waste and excess fluid from the blood), type 2 diabetes (high blood sugar, epilepsy ( is a brain disorder that causes recurring unprovoked seizures). Insomnia (difficulty falling asleep). Record review of CR#1's MDS dated [DATE] revealed the resident was coded for Cognitive Skills for Decision Making as severely impaired, indicating that CR#1 was not able to make sound decision. She was coded as total care for ADL's, incontinent of bowel and bladder and was fed via a feeding tube. Record review of CR#1's care plan revealed the resident was fed via a feeding tube due to dysphagia. CR#1 will be free from aspiration. Intervention: monitor/document and report to MD PRN: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Tube dysfunction or malfunction, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Record review of nurse's notes written on [DATE] by LVN T revealed resident returned to facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 5 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0684 Level of Harm - Immediate jeopardy to resident health or safety via ambulance with [family member accompanying resident. Resident in stable condition. Vital signs within normal limit. incontinent b/b. NPO. continues feeding of diabetisource 70ml/hr. 40ml/hr. flush. Antibiotic noted for UTI, resident bedbound. total assist x1. stage 3 wound @ L hip and wound @ ankle. resident lying in bed watching TV. bed in lowest position. call light in reach. will continue to monitor. Record review of Resident #1s' Physician Orders revealed the following orders dated: Residents Affected - Few [DATE]: Check G-tube placement by aspirating gastric contents before feeding or before giving medications, every shift. [DATE] nurses' revealed start date [DATE]: G-tube: h2o 30-50 ml PGT before and after medication administration - monitor q shift. G-tube: h2o 5-10 ml PGT between each medication - monitor q shift. G-tube: check for residual prior to feeding / medication administration q shift. hold feeding / medication & notify MD if residual > 100 ml. Record review of the nurse's progress notes revealed no documentation regarding CR#1's activities on [DATE] in the day until 9:05pm when CR#1 became unresponsive and was sent to the hospital via 911. Record of the CR#1's assessment sheet revealed no assessment for CR#1 during the morning of [DATE]. Record review of the hospital notes dated [DATE] revealed that 911 was called at 9:22pm and CR#1 was sent to the hospital as per family request, the resident coded and was rerouted to a hospital closer to the facility. Record review of the hospital documentation dated [DATE] revealed CR#1 coded CPR initiated, and the cause of the resident death was cardiac arrest. Record review of the Autopsy Report dated [DATE] read in part . date of death [DATE]. Respiratory System: Aspirate foreign material consistent with gastric content - trachea, right and left bronchi and lungs. Pulmonary congestion and edema (combined weight 1105 grams) [PHONE NUMBER] grams (Right and left lobes lungs). Serous effusion (approximately 150 ml) right pleural cavity. Gastrointestinal System: Severe fecal impaction with dilated rectum. Polyp (up to 1.2 cm) descending colon. Status - Post gastrotomy placement in tack (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 6 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0684 Hepatic and Binary System Level of Harm - Immediate jeopardy to resident health or safety Atrophy (820grams: ref: [PHONE NUMBER]), liver. Residents Affected - Few Genitourinary System: Cholelithiasis (multiple pigmented gallstones - up to 1.2cm), gallbladder. Probable benign nephrosclerosis, right and left kidney. Opinion: Based on the findings of the reasonable medical probability investigation information available at this time it is the opinion the decedent CR#1 died as a result of aspiration complicated of atherosclerotic cardiovascular diseases. In an interview on [DATE] at 1:50pm LVN B said he worked with CR#1 on [DATE] and he did not see any change in her condition. He said she did not vomit on his shift, and no one told him that she was vomiting. Further interview with LVN B, he said he gave CR#1 her medication that morning and he did not see any vomit on her. In an interview on [DATE] at 2:10 p.m. LVN A said she worked with CR#1 on [DATE] and she did not see any change in her condition, and she did not see her vomiting, nor did she see any vomit on her. She said she was new and was working with another nurse but did not remember what time she saw CR#1. In an interview with CNA G on [DATE] at 2:15pm she said she provided care to CR#1 on [DATE] and she did not see her vomiting and she did not see any vomit on her, and she did not see any change in her condition. She said if there was any change in the resident's condition, she would report it to the nurse. She was asked at what time did she see CR#1 and she said the beginning of her shift and the next time was when she was passing breakfast tray around 8.00 am, she peeped at her at from the door of the room and she was okay . She was asked when was next time after 8:00am that she saw CR#1, she said she could not give a direct time. She was asked who turned the feeding pump off when care was provided to residents with a feeding tube. She said, if the nurse was not available, she would turn the pump off and on. When asked if she had permission to turn the pump off and on, CNA G did not answer. Observation on [DATE] at 3:00pm of the motion camera footage (a camera that only records when it detects motion in the field of vision) dated [DATE] at 7:15 am revealed CR#1 was in bed with the head of the bed elevated, her left hand was resting on her stomach and was contacted to the lower extremities. Observation revealed the resident vomited up large amount of brown liquid emesis all over her neck, stomach, and running down her left hand. Further observation revealed the CR#1 was lying in her vomit and no one checked on her every two hours as per facility policy. Observation of the camera footage dated [DATE] at 11:15 am four hours later a CNA that was later identified as CNA H went in the room to check on CR#1. She pulled back the covers and muttered something and left the room. She later returned with three aides who were later identified as CNA G, CNA J and CNA K. Further observation revealed CNA H and G removed the covers and started providing care to CR#1, while CNA J stood, a little way from the resident and CNA J who brought some linen, put it on the table and stood near the doorway. Observation revealed CNA G and H did not call the nurse to turn the pump off. They provided care to the resident and left the room. Further observation revealed no evidence that the nurse entered the room during and after the care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 7 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on [DATE] with LVN B at 1:00 pm, he said when he gave medication to CR#1 she was fine. He said he was never abusive to any resident. He said he took care of CR#1 and he never saw any vomit and he was not aware the resident had vomited. He was then told that there was camera footage. At that point he said he wanted to see the camera footage. Interview with CNA H on [DATE] at 10:20am she said she was assisting CNA G providing care to CR#1 and she saw what looked like milk on her bed. She said she did not report it to the nurse because she thought CNA G reported it to the Charge nurse since CR#1 was her patient. Further interview with CNA H, she said usually if there was a change in a resident's condition, she would have reported it to the nurse. Interview with CNA I on [DATE] at 10:25am, she said she was assisting CNA G and &H she did not see CR#1 vomiting and she did not see any vomit on her. She said if she saw the vomit, she would report it to the nurse. In an interview with CNA G on [DATE] at 10:30am, she said she did not see any vomit on CR#1's body. She said if there was a change in condition, she would report it to the nurse and physician and she insisted she did not see anything on CR#1's body. She said she and CNA H gave CR#1 a bed bath and she was fine. In an interview on [DATE] at 11:00 am with CNA G after she viewed the camera footage dated [DATE] she had a look of shock on her face. When asked if she was the CNA on the camera she said yes. At that point she was asked if the nurse was called to turn the feeding pump off, she said No. Further interview on [DATE] with CNA G after viewing the video, she still insisted she did not see anything wrong with CR#1 even when she saw her vomiting on the video. She was then asked at that point if pump was turned off during care and she said No. Asked if the nurse should be called, during care she said yes. Asked why she did not call the nurse she said the nurse was not around. Interview on [DATE] at 1:00pm with LVN B after viewing the camera footage he said that was a lot of vomit from CR#1. He said he did not smell any vomit, and if he had seen the vomit on CR#1 he would have cleaned her up. He said he gave CR#1 her medication around 9:00am and he assessed her G-Tube site, he checked for residual and did not see any change in her condition. He said he was not called when the staff was providing care. Further interview with LVN B he said when he gives medications to residents who were fed via feeding tubes he usually checked for placement, residual, ensuring that the head of the bed was elevated, and resident was not at risk for aspiration. He said at the end of his shift the resident looked okay. In an interview with the DON on [DATE] at 12:03pm she said she was new to the facility and was not around when the incident took place. She said her expectation was for the CNAs to observe residents and report any changes in their condition to the nurse. She said the expectation of the nurses were to do thorough assessments of residents when they do rounds, and when the CNAs report changes to them they should notify the physician of the change. She said based on the video footage there was no way anyone should have missed the vomit on CR#1. She said they have lots of work to be done and they will have to in-service the staff. She said moving forward she will ensure orders were checked and document on the MARs. Nurses will have to document any changes in resident's condition in the resident's clinical records. She said residents were to be checked on every two hours and as needed and the stop and watch will be put in place. She said there was a form at the nurse's station and the aides were expected to fill them when providing care out and give them to the nurses for follow up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 8 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview with the Administrator on [DATE] at 12:10pm she said she was new to the facility but based on the situation, the IJ came because of the lack of education and training. She said some staff were practicing out of their scope of practice and ignoring what needed to be done correctly. She said there were lots of in-servicing to be done. In an interview on [DATE] at 3:52pm the MD said he was CR#1's doctor and he was not aware that she had vomited on the morning of [DATE]. He said he was called on the night of [DATE] that CR#1 had a change in condition and was not responding and he gave orders for the resident to be sent to the hospital 911. He said the resident was sent out and later died. The Administrator and DON was notified on [DATE] at 1:43 p.m ., an Immediate Jeopardy situation (IJ) was identified due to the above failures. The Administrator was provided the IJ template on [DATE] at 1:50 P.M. and a Plan or Removal (POR) was requested. PLAN OF REMOVAL. Immediate Action Patient was discharged from facility on [DATE]. All relevant staff members were removed from the facility pending investigation. All other staff CNAs and nurses were immediately and thoroughly in serviced on G-Tube care (when performing care, a nurse is needed to disconnect patient from feeding and patient is to be pulled up in bed and HOB should be no lower than 30 degrees before having nurse to reconnect feeding. Also, report any findings they believe is vital such as patient color, vomiting or spit up to nurses, and rounding every two hours and as needed, and the degree at which a patient at risk for aspiration should be angled in bed, in-service by DON, and ADON. Signed in-service sheets reflecting education were also completed. On [DATE] and [DATE]. All nurses and nurse assistants verbalized understanding and signed in-service reflecting understanding. 1/26 and 1/ 27 Over the phone in-service completed by ADON for staff not in facility and will have in-service sign in sheets available for signing at their next scheduled work date. All involved parties, CNA, and LVN, suspended pending investigation on [DATE]. Upon further investigation, all allegations of neglect were found substantiated, and both parties were immediately terminated on 1/27. On [DATE], MD was notified of IJ, verbalized understanding. Enteral Feeding/Care Policies reviewed, and all staff, nurses and CNAs received copies and signed confirming receipt on 1/27. No changes were made to the policy. All enterally fed patients assessed by DON and ADON and orders implemented into PCC for Q2hour rounding and as needed and CNA rounding confirming completion of ADLs (Activities of Daily Living) and G-tube care requiring nurse documentation on 1/26. Change of condition in-services requiring nurses to document any change of resident outside of normal status, CNAs required to complete stop and watch forms depicting any change noticed in residents conducted by DON and ADON on 1/26 and 1/27. Orders will be integrated into the system ensuring rounding is complete every two hours, HOB are at the proper height of no lower than thirty degrees and no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 9 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few higher than forty-five. Orders will be implemented into system depicting times for patients to be repositioned and changed as well as any applicable physician orders, ensuring patients are attended to every two hours and as needed. Monitoring the POR on [DATE]: During the survey monitoring, the Administrator was interviewed regarding what she believed was the root cause of the IJ. The Administrator believed that a thorough assessment was not done by the nurse when medications were given to CR#1 and the aides did not report to the nurses when they saw what looked like milk on CR#1. There was a plan in place to monitor this issue, and the retraining of nursing staff and checking on residents every two hours avoid this issue occurring again. The Administrator expects the Director of Nursing to monitor all the systems daily as it relates to the IJ tags, physician notification and ensuring thorough and immediate documentation in resident medical records. During the survey monitoring, the Director of Nursing (DON) was also interviewed regarding what she believed was the root cause of the IJ. The DON believed if CR#1 was assessed properly and the CNAs reported what they saw when they were providing care the outcome might have been different. The DON plans to monitor this issue by assessing all residents that were fed via a feeding tube and document in PCC. Residents were checked every two hours and as needed. Residents that were fed via a feeding tube, bed should be set no lower than at 30 degrees angle. The DON expectations of the RN's and LVN's to follow protocols, document and report any change in condition to the doctor. The DON indicated she personally evaluated each resident, who were fed via a feeding tube. On [DATE] In-Service trainings initiated by the ADON to licensed nurses on Enteral Feeding and changes in condition. In an interview on [DATE] at 3:17pm LVN C said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. She verbalized understanding of in-service provided. In an interview on [DATE] at 3:51 pm CNA B said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. She verbalized understanding of in-service provided. In an interview on [DATE] at 3:57pm CNA K said she was in-serviced on G-Tube (not touching the pump, nurses should turn the pump on and off), reporting change in condition to the nurses, abuse, and neglect. She verbalized understanding of in-service provided. In an interview on [DATE] at 4:00pm CNA D said he was in-serviced on G-Tube (not touching the pump, nurses should turn the pump on and off), reporting change in condition to the nurses, abuse, and neglect. He verbalized understanding of in-service provided. In an interview on [DATE] at 10:08 pm CNA E said she was in-serviced on G-Tube (not touching the pump, nurses should turn the pump on and off), reporting change in condition to the nurses, abuse, and neglect. She verbalized understanding of in-service provided. In an interview on [DATE] at 10:23pm LVN D said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. The staff verbalized understanding of in-service provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 10 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on [DATE] at 12:26pm LVN S said she was in-serviced on resident rights, abuse/neglect, G-Tube feeding (nurses should turn the pump on and off), report change in condition to the doctor and documentation. She verbalized understanding of in-service provided. In an interview on [DATE] at 1:30pm with RN B she said she was in-service on change in condition, G-tube feeding, report to the doctor and assessing residents who are fed via a feeding tube. She verbalized understanding of the in-service provided. In an interview on [DATE] at 4:05pm LVN F said he was in-serviced on abuse neglect, change in condition, policies and regulations on what CNAs are allowed to do that is not to turn on and off the feeding pump and report change in condition to the nurses. He verbalized understanding of in-service provided. In an interview on [DATE] between 11:00am and 3:00pm with CNA I, CNA J, CNA L and CNA N they all said were in-serviced on change in condition, abuse and neglect, G-T (CNAs not to touch the pump because that was the nurse's job), reporting and documentation. They all verbalized understanding. Record review of the POR revealed in-service signatures of all medical personnel on change of condition, abuse neglect, G-tube care, charting documentation, and reporting. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 1:18pm. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 11 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 5 Residents (Resident #2 and, Resident #3) reviewed for medical records accuracy, in that: Resident #2's and Resident #3's January 2024 Medication Administration Record (MAR) did not reflect documentation for medications given or not given. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. Findings Included: Resident #2 Record review of Resident #2's admission face sheet revealed he was [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included type 2 diabetes (high blood sugar), dysphagia (difficulty swallowing), oropharyngeal phase (moving of food or, lack of coordination, major depressive disorder (mental illness), insomnia (difficulty sleeping), essential hypertension (high blood pressure), hypothyroidism (thyroid gland doesn't produce enough hormone), hypotension, (low blood pressure), altered mental status (mental function), other supraventricular tachycardia and cerebral infarction(disruptive blood flow to the brain). Review of Resident #2's MDS assessment, dated 12/17/2023 revealed the resident was coded as severely impaired for cognition and was incontinent of bowel and bladder and was total care for activities of daily living and was fed via a feeding tube. Record review of Resident #2's physician orders revealed an order dated 11/11/2023 for, Protonix Delay release 40mg give one tablet in the afternoon for ulcer drug at 4:00pm. Quetiapine Fumarate give 2 tablets by mouth 3 times a day for mental health (8:00am, 2:00pm and 8:00pm. Lorazepam 1 mg by mouth two times a day at 8:00am and 4:00pm. Buspirone 5ml three times a day at 9:00, 1:00pm and 5:00pm Record review of Resident #2's January MAR revealed no documentation on 01/04/2024 that protonix (ulcers drugs) was given at 4:00pm, Quetiapine Fumarate was given on 1/4/2024 at 2:00 pm for mental health. On 1/4/2024 and 1/20/2024, Lorazepam was not documented as given for anxiety at 4:00pm. On 01/4/2024, buspirone for mental health was not documented as given at 1:00pm and 5:00 pm. Resident #3 Record review of Resident #3's admission face sheet revealed he was a [AGE] year-old male who was admitted to the facility 7/2/2021 and readmitted on [DATE]. His diagnoses included, essential hypertension (high blood pressure, angina pectoris, pain, cerebral infarction, constipation (difficulty having a bowel movement) , gastroesophageal reflux disease(heart burn), anemia, dysphagia, moderate protein calorie malnutrition(deficiency of energy, protein and micronutrient), muscle weakness, dysphagia (swallowing problems) , diastolic (congestive ) heart failure (condition in which the heart's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 12 of 13 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505 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 0842 Level of Harm - Minimal harm or potential for actual harm main pumping chamber becomes stiff and unable to fill properly), contracture of left knee and left hand (tightening of the muscles and tendon), type two diabetes (high blood sugar), hypoxia (level of oxygen in the body tissues) , hydrocephalus (buildup of fluids in the brain), hyperlipidemia (high levels of fat in the blood), Candida stomatitis (infection in the mouth), encephalopathy (brain disease), traumatic hemorrhage of cerebrum (nonpenetrating or penetrating trauma to the head. Residents Affected - Some Review of Resident #3's MDS assessment, dated 12/01/2023 revealed the resident was coded as severely impaired for cognition and was incontinent of bowel and bladder and was total care for activities of daily living and was fed via a feeding tube. Record review of Resident #3's physician orders revealed an order dated 07/01/2023 for Oxybutynin Chloride 5mg every 8 hours for overactive bladder at 7:00 am 3:00pm and 11:00pm. Record review of Resident #3's January MAR revealed no documentation on 01/05/2024 that Oxybutynin was given for overactive bladder on 1/05/2023 at 3:00pm. During an interview with the DON on 01/24/2024 at 3:45pm the DON said the expectation of the nursing staff was to document on the MARS when medications were given or refused. She said if medications were refused, they should put a code in that indicates the resident had refused the medications and document in the nurse's notes. She said there should be no blanks on the MARS. She said she was new to the facility, and she will have to in-service the staff on documentation. During an interview on 1/29/2024 at 3:35 p.m. RN B said she worked mostly on the weekend, so she was not the one who was responsible for giving the medications. She said when medications were given, they should document on the MARS and if the resident refused for whatever reasons they should code on the MARS and document in the nurses the reason why the medication was not given. She said if the resident was not in the building it should be documented in the nurse's notes. She said there should be no blanks on the MARS because it would be difficult to determine if medications was given or not and treatment was done or not done. Record review of the facility policy titled Charting and Documentation with an implementation date of April 2008 read in part . Policy Statement All services provided to the resident, or any changes in a resident's medical, mental condition, shall be documented in the resident's medical record. Policy Interpretation and Implementation. 1. All observations, medications administered, services perform etc Must be documented in the resident's clinical records. 3. All incidents, accidents, or changes in the resident's condition must be recorded FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 13 of 13