Health inspection·January 16, 2026

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission for 3 (Residents #12, #14, #30) of 12 residents reviewed for comprehensive assessment accuracy and timing. The facility failed to complete Residents #12, #14 and #30's admission comprehensive MDS assessments within 14 days following admissions to the facility. This deficient practice could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #12 Record review of Resident #12's face sheet revealed an 81- year- old male, admitted to the facility on 12\18\2025. His diagnoses included congestive heart failure, Diabetes (a condition where the body has trouble controlling sugar in the blood), chronic kidney disease, anemia (a condition in which the body does not have enough healthy red blood cells to carry adequate oxygen to its tissues), hyperlipidemia (Having too much fat in the blood), encounter with attention to tracheostomy (a surgical opening made in the neck to help a person breathe when they cannot breathe normally through the nose or mouth) and generalized muscle weakness. Record review of Resident #12's clinical records indicated Resident Record review of Resident #12's clinical records indicated Resident #12 had a 20-day entry MDS assessment dated 12\18\25 that was not completed. Resident #14 Record review of Resident #14's face sheet dated 1\13\26 revealed a [AGE] year-old female admitted to the facility on 12\24\25. Her diagnoses included Acute and chronic respiratory failure with hypoxia. (condition where the body does not receive enough oxygen due to respiratory failure), chronic pain, pressure ulcer of left heel, infection of the skin and subcutaneous tissue, unspecified essential (primary) hypertension ( High blood pressure), protein-calorie malnutrition, heart disease, type 2 diabetes mellitus with diabetic neuropathy, insomnia ( Lack of sleep), depression, cerebral infarction( Also known as stroke) , dysphagia following cerebral infarction, cerebrovascular disease, dementia, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #14's clinical records indicated Resident #14 had a 5-day entry MDS assessment dated 12\24\25. Record review indicated section A was completed. Record review of Resident Page 1 of 4 676332 676332 01/16/2026 The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #14's admission MDS dated 12\30\25 indicated the admission MDS was not complete as of 01\13\26 which was 20 days after admission. Resident #30 Record review of Resident #30's face sheet dated 1\12\26 revealed an [AGE] year-old female admitted to the facility on 04\09\24 and readmitted on 01\05\26. Her diagnoses included Ankylosing spondylitis of lumbosacral region (inflammation can cause some of the bones in the spine, called vertebrae, displaced intertrochanteric fracture of right femur, closed fracture, history of falling, senile degeneration of brain ( a range of neurological condition) , osteoarthritis, right knee right artificial knee joint, wedge compression fracture of second lumbar vertebra, major depressive disorder, dementia, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #30's clinical records revealed the last Quarterly MDS assessment was dated 08\21\25. Record review revealed an incomplete admission MDS dated 11\26\25 that indicated in progress. During a phone interview on 01\14\26 at 12:57pm, facility MDS coordinator-A said she was new to the facility and still in training. She reported that she has not yet fully acquired the required knowledge to independently complete MDS assessments but has access to resources and support personnel who is assisting her. She acknowledged that she is behind in completing the required MDS assessments and attributed this, in part, to her newness in the role. She stated that she has been employed at the facility since late October 2025 and has completed only two to three MDS assessments so far. She further stated that when she began employment, the facility did not have an on-site MDS Coordinator, and that MDS responsibilities were being managed by a corporate nurse, who is also providing her training. The MDS Coordinator confirmed her understanding that CMS requires comprehensive MDS assessments to be completed within 14 days of admission. She further stated that failure to complete the MDS within the required timeframe may result in loss of Medicare\Medicaid reimbursement for the facility. She also acknowledged that delayed completion of the MDS can negatively impact residents by delaying the identification of needs and the development or implementation of appropriate care. During an interview with Regional MDS Coordinator B she stated that the facility was in the middle of a CHOW (change of Ownership), which resulted in the discharge of all residents. She reported so many MDS assessments to complete was difficult. She said she was the only staff member responsible for completing all the MDS assessments. She stated she is working as quickly as possible to complete the assessments but acknowledged that she is currently behind. She further stated that once the MDS assessments are completed, they are forwarded to the Registered Nurse (RN) for review and signature. She also demonstrated understanding that comprehensive assessments must be completed within a 14-day timeframe from the date of admission. She confirmed that when the MDS assessments are not completed in a timely manner, it could result in care plans that are incomplete, inaccurate, or delayed, leading to unmet needs of the residents. Record review of facility policy dated 05\05\25 titled Conducting an Accurate Resident Assessment revealed, Policy: The purpose of this policy is to ensure that all residents receive an accurate assessment, reflective of the residents' status at the time of the assessment, by staff qualified to assess relevant care areas. 676332 Page 2 of 4 676332 01/16/2026 The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505

F 0636 Provided MDS Policy did not address timing of MDS assessment. Level of Harm - Minimal harm or potential for actual harm 1. The Administrator will ensure that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Residents Affected - Few 2. Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths, and areas of decline. The assessment will be documented in the medical record. 3. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. 4. A registered nurse will coordinate the RAI completion process with the appropriate participation of health professionals. The registered nurse is responsible for certifying that the assessment has been completed. 5. Information provided by the initial comprehensive assessment establishes baseline data for the ongoing assessment of resident progress. 6. The physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments. Involvement of other disciplines is dependent upon individual resident status and needs. 7. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion 676332 Page 3 of 4 676332 01/16/2026 The Suites Pasadena 4900 East Sam Houston Parkway South Pasadena, TX 77505

F 0636 of the assessment. Whether the MDS assessments are manually completed, or computer generated Level of Harm - Minimal harm or potential for actual harm following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status. Residents Affected - Few 676332 Page 4 of 4