Health inspection·February 21, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm wanting everyone entering her room to wear a mask was because her immune system was already shot, and they have been having COVID-19. She said it had been months since they had COVID-19 in the building, but she still wants masks to be worn. She said she did not tell Nurse A anything about not wearing a mask because it is posted on the door and feels she does not need to tell her or staff to wear one every time they enter her room. Residents Affected - Few During an interview on 02/21/25 at 10:29 a.m., MA A said Resident #1's request to wear a mask when entering her room was being honored. She said the resident told her she did not have to wear a mask. She said she would ask the resident if she needed to wear a mask. MA went to resident's room, opened door, and asked Resident #1 while standing at the entrance to the room if she wanted her to wear a mask when she entered her room. Resident told MA A she wanted her to wear a mask. During an interview on 02/21/25 at 11:50 a.m., Nurse A said Resident #1 picked and chooses who she allows to enter the room with a mask, and who she does not want to enter the room without a mask. She said the resident gave her permission to enter the room without a mask. She said she was in her room because the resident wanted her television remote. She said the resident always allows her to go into her room without a mask. She said when the resident explained the sign to her, she said it was for the staff, and she was ok with the same staff going in and out of the room without a mask, but was not okay with it during COVID-19. She said she asked the ADON about the sign on Resident #1's door and was told it was the family's preference as the sign indicated. She said when she first started working at the facility, she would wear a mask, but there came a time when she was in the hall and the resident asked for her PRN medication. She said ok, but she needed to go get a mask, but the resident said it was okay she did not need one and so she went in and gave her medication . She said it was the resident's own preference that a mask be worn and that she was able to consult with the resident if she could enter without a mask. She said the resident gave her permission to enter without a mask earlier that day because she just needed her television remote. She said not honoring a resident's right could cause or be like mental abuse. During a follow-up interview on 02/21/25 at 12:35 p.m., Resident #1 said staff just came in her room and do not ask her if it is okay to enter without a mask. She said everyone comes in without a mask. She said staff have never asked her if it was okay for them to enter without a mask. She said she should not have to say anything because the sign in posted in their face on her room door. She said staff do what they want. She said her parents come and visit on Sundays and always wear a mask. She said it makes her feel disrespected when they go in her room without wearing a mask. During an interview on 02/21/25 at 11:34 a.m., the DON said if a resident wanted nursing staff to wear a mask when entering their room, the expectation was for the staff to meet their request. When asked about the consequence of not honoring a resident's request, she said she guessed it would affect them psychologically. She said if she were the patient, she would be upset. She said she was aware that Resident #1 had a sign posted on her room door saying something about asking to wear a mask upon entering. She said she was pretty sure the nursing staff was aware because there was a sign posted on the door. Record review of the facility's Statutory of Patients' Rights policy, dated 08/2024, read in part .Statement of Resident's Rights in Texas .The facility must encourage and assist you to fully exercise your rights .You have a right to .4. Be treated with courtesy, consideration, and respect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 (Resident #1) of 4 residents reviewed for dietary services. -The facility failed to honor Resident #1's food preference according to her meal ticket by serving her pork, which her meal ticket reflected she disliked. This failure could place residents at risk for possible weight loss, and a diminished interest in meals and quality of life. The findings included: Record review of Resident #1's admission Record, dated 02/21/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (autoimmune disease resulting in damage to the insulating covers of nerve cells in the brain and spinal cord), bipolar disorder (mental health condition that causes extreme mood swings), and muscle weakness. Record review of Resident #1's MDS Quarterly Assessment, dated 12/08/24, revealed a BIMS score of 13, indicating she was cognitively intact. Further review revealed resident required set up or clean up assistance (helper sets up or cleans up) with eating. Record review of Resident #1's Care Plan Report, undated, revealed the resident was on a regular diet with thin liquids. Observation on 02/21/25 at 10:14 a.m. of Resident #1's meal ticket, dated February 2025, revealed pork was listed as one of the resident's dislikes. During an interview on 02/21/25 at 10:14 a.m., Resident #1 said she did not eat pork because she was Muslim. She said the facility had been serving her pork and the last time it happened was that past Tuesday, 02/18/25. She said sometimes she would have them bring her something different or family will bring her food to eat. She said it makes her mad when she was served the wrong food. During an interview on 02/21/25 at 11:50 a.m., Nurse A said she had been working at the facility for maybe a week. She said Resident #1 has complained about something that was on her meal tray (item unknown) that should not be on there. She said she offered the resident a substitute and the dietary manager did as well, but she refused. During a telephone interview on 02/21/25 at 2:40 p.m., CNA A said she checked all the meal tickets. She said she knew Resident #1 did not eat pork. She said resident was served pork because she did not look under the food cap cover that was over the plate. She said she took the tray into the resident's room, lifted the top, asked if she wanted it, because she refuses a lot. She said she saw it was pork and took the tray back. She said the resident called her back to her room and gave her a note. She said she does not remember what the note said. She said Resident #1 told her she was not going to eat the meal. During a telephone interview on 02/21/25 at 2:22 p.m., Dietary Aide A said they prepared the food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 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 676332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in kitchen, rolled carts out, and the CNAs delivered the meals. She said meal tickets were printed out every day which told them the resident's name, diet, allergies, likes, and dislikes. She said the cook made the plate and they checked the meal ticket against the meal as they put them on the cart. She said if she sees the ticket and they were having something they do not like, they will try to accommodate with something they like. She said approximately a couple of weeks ago, Resident #1 wrote a note and had a CNA bring the note to the kitchen. She said the note said something about what she did not fucking eat. She said she went and spoke to Resident #1, told her they made a mistake, and asked her what she could get her to eat. She said the resident said she did not want anything and said she would not eat it if the President brought it there. During an interview on 02/21/25 at 1:27 p.m., the Administrator said she knew the serving of the wrong food items had been happening. She said staff would get the ticket, put it on the tray, and then deliver the meal without verifying if the meal was correct. She said the aides would say they knew by memory what residents ate what, but she told them no, they did not know by memory. She said Resident #1 received a pork chop for dinner about 2 ½ weeks ago and wrote a nasty note saying, I do not eat fucking pork, can't you read. She said on resident's meal ticket it said in two different areas, no pork. She said staff were now looking at the tickets. She said she did not know how it affected Resident #1 when she is served the wrong food item, as it is just a preference. She said she also moved pork over to the allergy area on the resident's meal ticket so she would not get pork. She said the Dietary Manager was on leave. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676332 If continuation sheet Page 4 of 4