Inspection·May 23, 2023

F 0661 Level of Harm - Minimal harm or potential for actual harm Record review and interview on [DATE] at 12:32p.m., with Social Services Designee, she said the SW Supervisor brought it to her attention this morning that CR#1's discharge summary was incomplete. She said she started discharge summary on admission and worked on it thought out the resident's stay. She said the discharge summary should be completed 72 hours after discharge. She said it was important to complet the discharge summary to know when and where the resident went and things they needed. Residents Affected - Few Record review of facility's Discharge Summary (not dated) revealed read in part: .Policy: It is the policy of this facility to ensure that a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 2 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 3 residents (Resident #7, Resident #16, and Resident #14) of 15 residents reviewed for accidents and supervision had an environment that was as free of accident hazards as possible. -Residents #7 and #16 were at risk for falls. The facility failed to consistently place fall mats next to their beds when the residents were occupying the bed. -Resident #14 was at risk for falls. The facility created an injury hazard by placing the resident's bed table in the pathway of a potential fall. These deficient practices could place residents at risk for injury. Findings Include: Resident #7 Record review of Resident #7's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was Dementia. Record review of Resident #7's quarterly MDS dated [DATE] revealed the resident had both short and long-term memory deficits and was cognitively severely impaired. The resident required extensive assistance with one-person assist with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS reflected the resident did not demonstrate steady balance without the assistance of staff during transfers. The MDS reflected Resident #7 exhibited impaired range of motion to all extremities. Section O: Special Treatments noted Resident #7 was on hospice. Record review of Resident #7's Care Plan initiated on 06/01/21 and revised on 4/24/23 read in part . Dementia, Fatigue, Limited Mobility, weakness, Date Initiated: 06/01/2022, Revision on: 09/20/2022. Target Date: 08/21/2023. Bed Mobility: The Resident required extensive assistance with one-person assist for repositioning in bed. Revision on: 06/18/2022. Bedfast: The Resident was bedfast all the time. Problem: At risk for falls r/t confusion. Goal: will be free of falls. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Fall mat on floor at bedside. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Follow facility fall protocol . Observation and interview on 5/21/23 at 9:15 am revealed Resident #7 lying in bed asleep. There was a floor mat by her bedside to her left. There was a floor mat standing against the wall to the right corner next to the window as you entered the resident's room. Observation on 5/21/23 at 12:20 pm revealed Resident #7 in bed asleep. There was no floor mat by her bedside. RN A said Resident #7 was a fall risk and she required floor mats (on both sides) by bedside while the resident was in bed and her bed had to be at the lowest position. She said it was the CNAs responsibility to ensure fall risks residents had their fall mats by their bedside while (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 3 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0689 Level of Harm - Minimal harm or potential for actual harm residents were in bed. She said the fall mat was meant to cushion the resident's fall. She could not recall the last-time she was in-serviced for fall prevention. She said the resident could fall and get injured if their fall mats were not placed by their bedside while in bed. Resident #16 Residents Affected - Some Record review of Resident #16's face sheet revealed a [AGE] year-old female who was admitted on [DATE] and re-admitted on [DATE]. Her diagnosis was history of falls. Record review of Resident #16's quarterly MDS dated [DATE] revealed the resident had a BIMS of 99 indicating the resident was unable to complete the interview. The resident had both short and long-term memory deficits, and she was cognitively severely impaired. The resident required extensive assist of two persons bed mobility. She required extensive assist of one person for transfers, dressing, eating, toileting, and personal hygiene. Record review of Resident #16's Care Plan revised on 02/17/2023 read in part . Focus: Resident #16 had an actual fall on 3/2/22--Fall--without injury; 8/19/22 - Fall with injury, date Initiated: 03/03/2022; Revision on: 02/17/2023. Goal: Resident #16 will resume usual activities without further incident through the review date, revision on: 03/11/2022, Target Date: 05/20/2023. 2 staff assist during showers, revision on: 08/23/2022, 8/19/22: Send to ER for eval and treatment as indicated. For no apparent acute injury, determine and address causative factors of the fall. Monitor/document /report PRN x 72h to MD for signs/symptoms: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation . Observation on 5/12/23 at 9:05 am revealed Resident #16 had mucus on her right eye. She was sitting in her wheelchair. She was making facial and hand gestures. This Surveyor pushed her call light. CNA DD came into the room and said the resident wanted to be transferred to her bed. CNA DD she made facial and hand gestures when she wanted to be transferred to bed because she was nonverbal. There was a floor mat standing against the wall to the left corner as you entered the resident's room. Observation on 5/12/23 at 11:00 am revealed Resident #16 lying in bed asleep. She did not have her floor mat by her bedside. The resident's floor mat was standing against the wall to the left corner as you entered the resident's room. Observation and interview on 5/12/23 at 11:55 am revealed Resident #16 lying in bed asleep. She did not have her floor mats by her bedside. RN A said Resident #16 was a fall risk because she had had about 3 falls in the past. She said CNAs were responsible for ensuring floor mats for fall risk residents were in place and their beds were lowered to the lowest position when residents were lying in their beds . She said the purpose of the floor mats was to cushion the resident's fall to prevent injury. She said CNA DD was supposed to place the resident's floor mat by her bedside when she laid her to bed. She said the charge nurse was responsible for ensuring CNAs were placing fall mats by resident's bedside while they were in bed. She said she could not remember the last time staff were in-serviced for fall prevention interventions. Resident #14 Record review of Resident #14's face sheet revealed an [AGE] year-old female who was admitted on [DATE]. Her diagnosis was Dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 4 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #14's quarterly MDS dated [DATE] revealed the resident had a BIMS of 7 out of 15 indicating the resident was cognitively severely impaired. The resident required extensive assistant with two-person assist for bed mobility and transfers. She required extensive assistance with one person assist for dressing, eating, toileting, and personal hygiene. The MDS reflected the resident did not demonstrate steady balance without the assistance of staff during transfers. The MDS reflected Resident #14 exhibited impaired range of motion to one lower extremity. Record review of Resident #14's Care Plan revised on 5/21/23 revealed the resident was not care planned for falls or fall mats by her bedside . Observation on 5/21/23 at 9:10 am revealed Resident #14 spending time with her family. She was lying in bed. There were no fall mats by her bedside. There was a square 3X3 flat cushion in front of the resident's bedside dresser. There was a fall mat standing against the wall to the left corner next to the window as you entered the resident's room. The resident's bed was raised. Observation and interview on 5/21/23 at 9:45 am revealed a CNA A enter the room with this Surveyor. The CNA A said Resident #14 was a fall risk and she was care planned to have fall mats by her bedside on both sides . She said she should have placed the resident fall mats by her bedside when the resident was in bed. She said the purpose of the fall mats was to cushion the resident's fall. She said the square 3X3 flat cushion in front of the resident's bedside dresser was not a fall mat. She said she did not know how it got there. CNA took the fall mat standing against the wall and placed it by resident's bedside. She said the resident's bed was at the lowest position. This Surveyor asked to assess it. CNA cranked the turning knob, and the bed was lowered to the lowest position after Surveyor intervention. Observation and interview on 5/21/23 at 12:20 pm revealed Resident #14 lying in bed asleep. She had fall mats by her bedside on both sides. There was a rolling table on top of the fall mat by resident's right side of the bed facing the window. RN A said Resident #14 was a fall risk and she required fall mats and her bed lowered to the lowest position. She said it was the CNAs responsibility to ensure fall risks residents had their fall mats by their bedside while residents were in bed. She said the rolling table should not have been placed on top of the fall mat because if the resident fell on that side, it could cause the resident injury. She said she could not recall when staff were in-serviced for fall prevention interventions. In an interview on 5/21/23 at 1:34 pm with the DON, she said she started working at the facility about 6 weeks ago. She said the Therapists assessed residents for fall risk and notified the MDS nurse so residents could be re-assessed, and care planned for fall risks. The DON said the MDS nurse notified the family if they became fall risk. She said fall mats and placing beds in the lowest position were used as interventions to prevent future falls. She said the CNAs were responsible for placing fall mats by resident's bedside while residents were in bed. She said the risk to residents when fall mats were not in place was injury. She said she could not recall the last time she in-serviced staff for fall prevention interventions. She said she had oversight to ensure nursing staff were following fall risk protocols. Record review of the facility's policy titled: Accidents and Supervision not dated read in part . 1. identifying hazards and risk. 2. evaluating and analyzing hazards and risk. 3. implementing interventions to reduce hazard and risk. 4. Monitoring for effectiveness and modifying interventions when necessary. Implementation of interventions: H. Facility-based interventions may include but are not limited to i. Educating staff. ii. repairing the device/equipment. 4. Monitoring and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 5 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete modification-monitoring: Monitoring and modification processes include: a. ensuring the interventions are implemented correctly. b. evaluating the effectiveness of interventions a. d. evaluating the effectiveness of new interventions. 5. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents . Record review of the facility's policy titled: Fall Prevention Program not dated read in part . High Risk: Implement universal environmental interventions to decrease the risk of resident falling, including, but not limited to: a clear pathway to the bathroom and bedroom doors. Bed is locked and lowered to a level that allows the residence. Feet to be flat on the floor when the resident is sitting on the edge of the bed. Call light and frequently used items are within reach. Adequate lighting. Wheelchairs and assistive devices are in good repair. Implement routine rounding schedule. Monitor for changes in residence cognition, gait, ability to rise, or sit, and balance. Encourage residence to wear shoes or slippers with nonslip soles when ambulating. Ensure eyeglasses, if applicable, are clean, and the resident wears them when ambulating. Monitor vital signs in accordance with facility policy. High risk protocols: the resident will be placed on the facilities fall prevention program. Indicate fall risk on care plan. Low/Moderate Risk: Interventions, including, but not limited to: assistive devices, increased frequency of Brown's, sitter, if indicated, medication regimen review, a little bit, alternate, call, system, access, scheduled, ambulation or toileting, assistance, family and caregiver or resident, education, and therapy services referral . Event ID: Facility ID: 676334 If continuation sheet Page 6 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 (Resident #20) of 1 resident reviewed for enteral nutrition. -Resident #20 was receiving enteral nutrition via a G-tube. The closed-system formula bag was not labelled with the start time. The deficient practice placed residents who require enteral nutrition at risk for complications including infection if the formula bag was not replaced within a safe timeframe. Findings Include: Record review of Resident #20's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnosis was dysphagia, oropharyngeal phase (difficulty swallowing). Record review of Resident #20's quarterly MDS dated [DATE] revealed the resident had both short and long-term memory deficits and had severely impaired cognition. The resident required two-person assistance with bed mobility and extensive assistance from one person for eating and transfers. The MDS reflected the resident had a gastrostomy (feeding) tube (G-tube). Record review of Resident #20's Care Plan revised on 05/21/2023 read in part . Resident #20 insertion site will be free of signs and symptoms of infection through the review date . The Care Plan did not address the labelling of the tubing of nutrition source. Record review of Resident #20's physician orders dated 03/08/2023 read, Pump: Isosource 1.5 kcal @ 50 ml/hr. per GT x 22 hrs. continuous every day. Turn off (down) at 4pm and Turn on (up) at 6pm. Observation on 5/21/23 at 9:20 am revealed Resident #20 lying in bed holding 3 stuffed animals. A family member was in the room holding her hand. The resident had Iso-Source Bag hanging on an IV pole. The time on the bag of the label was left blank. The label read, Iso-Source 5/21/23 room [ROOM NUMBER], 50 cc/hr. Observation and interview on 5/21/23 at 12:30 pm revealed Resident #20 lying in bed holding her 3 stuffed animals. Her family member was not in the room. This Surveyor asked RN A to review the label on resident's Iso-Source bag and she said the label should have the time it started on the bag. She said the purpose of the date was to ensure it was changed timely within 24 hours. She said the risk to the resident if they did not get changed timely was infection. She said the night shift nurse must have forgotten to record the time and she did not catch it during her morning rounds. She said she could not recall the last time she was in-serviced for how to label Iso-Source bags. In an interview on 5/21/23 at 1:34 pm with the DON, she said the night nurses had to change the Iso-Source bags and tubing every 24 hours. She said the nurses were supposed to document their initials, date, time, rate, resident's name, and room number for any resident who fed through a tube . She said it was important to ensure the bags were labelled properly so they could be changed every 24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 7 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0693 Level of Harm - Minimal harm or potential for actual harm hours. She said nurses often missed recording the time. She said the night nursing staff changed them between 7pm-10pm. She said as the DON, she made it a point to monitor the labels daily because based on her experience at other facilities, she knew it was problematic. She said if the bags were not changed timely, the risk to the resident was infection. She said she in-serviced staff shortly after her hired date six weeks ago . She said the failure occurred because she had not in-serviced staff recently. Residents Affected - Few Record review of the manufacturer (Nestle) Hang Time Guidelines (no date) revealed the closed system enteral feeding should be replaced at least every 48 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 8 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure respiratory care was provided with care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #30) of 1 resident reviewed for respiratory care. Residents Affected - Few -Resident #30's oxygen nasal cannula tubing was dated 2/12 and not stored properly when not in use. -Resident #30's nebulizer mask and tubing were not dated and not stored properly when not in use. This these deficient practices could place residents receiving respiratory care at risk for respiratory infection leading to pneumonia. Findings Include: Record review of Resident 30#'s face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and Asthma. Record review of Resident #30's quarterly MDS dated [DATE] revealed the resident had a BIMS of 12 out of 15 indicating the resident had moderate cognitive impairment. The MDS reflected additional diagnoses of acute respiratory failure and septicemia (systemic infection). Record review of Resident 30#'s Care Plan revised on 01/30/2023 read in part . Resident #30 has altered respiratory status/difficulty breathing r/t acute respiratory failure, COVID-19, pneumonia, and COPD, pleural effusion (excess fluid buildup around the lungs). Goal: Resident #30 will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date . The section 'interventions' did not address the nebulizer or the oxygen tubing. Observation and interview on 5/21/23 at 9:50 am revealed Resident #30 lying in bed eating breakfast. There was a nebulizer on top of her dresser drawer by her bedside. The tubing (not dated) to the nebulizer was inside the first drawer with the mouthpiece laying on stacks of paper documents, a crème lotion bottle, and other personal items. There was a nasal cannula with the tubing dated 2/12. Neither the tubing's nor the mouthpiece were bagged while not in use. There was a Ziplock bag in the drawer with no date on the bag. The Resident said staff stored the tubing and mouthpiece in the first drawer. She said the dresser drawer by her bedside was beyond her reach. She said she received breathing treatments for COPD. She said she had been using oxygen more frequently after she recently moved out of room [ROOM NUMBER] because it had mold. In an interview on 5/21/23 at 12:40 pm with RN A, she said tubing to oxygen or nebulizer treatments should be changed every 48 hours. She said the tubing, nasal cannulas, and mouthpiece should be dated and stored in a Ziplock bag while not in use. She said the Ziplock bag should be dated as well. She said Resident #30 was receiving oxygen PRN at 1.0 milliliters for congestive heart failure. She said the nursing staff was monitoring her saturation and the resident could verbalize feeling shortness of breath. She said she noticed the resident was requesting oxygen more frequently since she moved from room [ROOM NUMBER] last week. She said she was unsure of what the facility's policy was for changing and dating tubing's because she had only been at the facility for six weeks. She said the respiratory therapist changed the tubing's throughout the facility. She said she did not know who left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 9 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident #20's tubing's and mouthpiece in drawer not properly bagged while not in use . She said the risk to residents was cross-contamination leading to infection. She could not recall the last time she was in-serviced for infection control or dating and storing tubing's and mouthpieces for pulmonary associated treatments. In an interview on 5/21/23 at 12:55 pm with Respiratory Therapist, she said she had been at the facility for 6 weeks as PRN. She said she worked one day per week (Sundays) between 8 to 12 hours. She said she was responsible for changing resident's tubing's, nasal cannula, and mouthpiece weekly on Sundays. She said the tubing should be dated and stored in a Ziplock while not in use to prevent cross-contamination leading to infection. She said she was in-serviced upon her hired date six weeks ago. She said she did not know how the failure occurred because she changed the resident tubing on Sunday, 5/14/23 so someone came behind her to change it and mistakenly place a date of 2/12. In an interview on 5/21/23 at 1:17 pm with the DON, she said the past Respiratory Director could have been the person who changed the oxygen tubing for Resident #30. She said the resident had PRN orders for oxygen. She said she was on 2.0 liters about 6 weeks ago when she started. She said residents that needed nasal cannula or nebulizer mouthpieces and tubing upon admission was set up by the Respiratory Therapist and it was their responsibility for dating the nebulizer masks and tubing and nasal cannula tubing's and humidifiers upon set up. She said the nebulizer mouthpiece and nasal cannula tubing was placed in resident's bedside table in the first drawer and should be stored in a closed Ziplock bag. She said the bag had to be dated as well. She said the purpose for dating Ziplock bags, nebulizer tubing's, masks, and nasal cannula tubing's was for respiratory staff to know when to change them out. She said residents could get infection when they were not changed out. She said she could not recall the last time staff were in-serviced. She said the Respiratory Director would have oversight, but he was no longer employed with the facility since 5/18/23. She said she had oversight during the transition of hiring a new Respiratory Director. Observation and interview on 5/22/23 at 6:25 am revealed Resident #30 lying in bed watching TV receiving 2.5 milliliters of oxygen infusion. There was a nebulizer on top of her dresser drawer by her bedside. The tubing (not dated) to the nebulizer was inside the first drawer with the mouthpiece laying on stacks of paper documents, a crème lotion bottle, and other personal items. There was a nasal cannula with the tubing not dated. Neither the tubing's nor the mouthpiece were bagged while not in use. There was a Ziplock bag in the drawer with no date on the bag. The Resident said staff changed the oxygen tubing yesterday (5/21/23). She said she could not recall the last time it was changed. She said she has been telling the nursing staff that she was needing oxygen more frequently since she moved out of room [ROOM NUMBER] last week due to the mold. Record review of the facility's policy titled: Nebulizer Therapy not dated read in part . Care of equipment . 1. Clean after each use. Disassemble parts after every treatment. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5 shake off excess water. 6 Air dry. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a Ziplock bag. 8 Change nebulizer tubing every seven days or PRN. Date tubing or bag. 9. Periodically disinfect unit . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 10 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 of 1 facility reviewed for posted staffing. Residents Affected - Many -The facility failed to post the daily staffing information for 05/21/2023. This failure could affect all residents and place them at risk of not having access to information regarding staffing data and facility census. Findings include: Observation and record review on 05/21/23 at 9:27 a.m., with the DON and the Business Office Manager revealed there was no posting for 05/21/2023. When asked how do they monitor to ensure the required postings are updated and in place. The DON said, I have always seen it by the front door. But it's not there today. The BOM said, I have seen it on the wall by the nurses station. This Surveyor followed the DON and BOM to the nurses station. The posted staffing information was dated 05/15/2023. The DON said it was important to post daily staffing information to inform how many residents were in the facility, acuity for the resident and family to know. In an interview on 05/22/23 at 3:19 p.m., with the Administrator and the DON, the Administrator acknowledged the staffing should be posted daily. He said the Lead CNA was responsible for changing the posting daily. He said it was important to post the staffing information to know how many residents were in the facility. Staffing information for the potential people coming to the facility. He said the posting should be at the front and at nurses station. In an interview on 05/23/23 at 11:53a.m., with the Lead CNA, she said she worked Monday through Friday at this facility. She said she used facility provided app (application) to print the daily staffing information. She said she could not remember the last time she posted the staffing information but knew she needed to post it daily for family and residents to see the census. Record review of facility's Nurse Staffing Posting Information policy (undated) revealed read in part: .Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 11 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: The facility failed to label and date food stored in the dry goods storage, refrigerator, and deep freezer. There were chemicals stored (by the 3-compartment sink) in an open area in the kitchen. The kitchen staff did not change gloves when changing tasks. The staff did not wash their hands upon entering the kitchen and they did not wash hands properly. The kitchen staff did not use the red sanitizing bucket to wipe down preparation countertops during food prep and meal service. The kitchen staff failed to wear hairnets properly while working or entering the facility's kitchen. These failures could place all residents who eat food served by the kitchen at risk of cross contamination and food-borne illness. Findings Included: During observation and interview on 05/21/23 beginning at 08:15 am during a walk-through of the kitchen accompanied by the cook revealed the following: Refrigerator : (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 12 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0812 Dirty onion peels on the floor. Level of Harm - Minimal harm or potential for actual harm 16 ounce of hamburger buns not sealed properly. Residents Affected - Many 24-12-ounce bags of tortillas outside of the original box dated 5/18/23 not labeled. 5 wrap tortillas out-side of the original box not dated and not labeled. Deep Freezer: The bottom of the freezer had frozen dirty ice particles. The cook said the freezer had not been cleaned in seven months. 5lb chicken dated and not labeled. 16-ounce bag of French fries outside of the original box not labeled. 4 mini pancakes not dated and not labeled. 16 ounces of cookie dough not dated and not labeled. Dry Pantry: 2 Dented cans stored with undented cans 106 ounces of chicken noodle, 106 ounces of sliced pears). Barbecue sauce stored with overflow of sauce leaking out at the top of the lid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 13 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0812 1-32 ounce of [NAME] food coloring rim and outside of the bottle was sticky with food coloring Level of Harm - Minimal harm or potential for actual harm drippings. - Residents Affected - Many 40lb bin with thickener not sealed properly. The [NAME] said the thickener not sealed properly expose the thickener to cross contamination. Observation and interview on 5/21/23 at 8:15am accompanied by the [NAME] revealed a 1-gallon bag of disposable napkins not sealed stored under a preparation countertop. There were 20 Bananas in a storage container stored next to pots, pans, and bowls under neat a preparation countertop. There were chemicals (polish Ecolab, medallion steel cleaner and polish, oven, and grill cleaner aerosol 20oz) stored next to pots and pans. The [NAME] said the chemicals should be stored in the chemical closet to prevent cross contamination. There were cooking pots, pans, ladles and serving spoons hanging off a cooking rack located near kitchen air vents. Observation and interview on 5/21/23 at 8:45am with the Dishwasher revealed the dishwasher took a blue cloth from an open box (underneath a preparation countertop located by the air vent covered with cake dust) to wipe the dishes dry. She looked up at the vent in the kitchen and said it look like mildew or something fuzzy hanging from the vent. Observation and interview on 05/22/23 at 10:46am revealed the [NAME] took bell peppers out of the bin slicing, cutting to prepare for the frying pan. She touched the dirty dishes and returned to touch the bell peppers. She said she did not wash the peppers before slicing and cutting them. She picked up the bell peppers and mixed them in with the cooked beef patties off to the right side of the same container. She said she needed more space, so she placed the bell peppers in the same container with the beef patties. She said there are some residents who do not like bell peppers. The [NAME] removed the temperature gauge from the ice water (the ice water had food particles inside the glass) and placed it into the vegetables without cleaning it with an alcohol wipe; the gauge was in the ice water; the cook placed the temperature gauge into the pureed food used the same alcohol pad and placed it into the ice glass of water. The [NAME] poured the glass of ice water out of the container, but she did not wash the glass she added ice and water to the glass and continued using the temperature gauge to check the temperatures of the food. During an interview on 5/23/23 at 11:41am, the Dietician Manger/ Activity Director, said she is the Dietary Manager over the kitchen. She said every morning she does her walk-in inspections, daily inventory, audit food, check items dated and labeled. She said the dented cans should go outside of the storage room or in her office until she returns them to the food company. She said the refrigerator, the standup freezer and the deep freezer should be clean. She said everything should be dated and labeled. She said nothing should be upside down and nothing should be left opened and turned in different directions. She said all boxes should be closed, dated with the name placed on the box faced in the direction that is readable. She said all the seasoning should be wiped down individually after each use. She said all the individual seasoning should be dated properly and facing toward the front. She said the chemicals are to stay in the storage area. She said no food should be out in the open while using chemicals. She said the staff had an in-service on hand washing and infection control April 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 14 of 15 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 676334 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chelsea Gardens 4422 Riverstone Blvd Missouri City, TX 77459 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 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 5/23/23 at 2:00pm, the Administrator, he said he walked through the kitchen and made changes where he saw there was a need. He said he checked to make sure items are dated. He said he would eat from the kitchen to check the quality and the temperature. He said the chemicals should not be in the open area where the food is stored. He said if the food temperatures are not correct for the residents' pathogens can enter the food. Residents Affected - Many There were two G-tube feeding at the facility. Record review of the facility's policy titled: Routine Cleaning and Disinfection : It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Record review of the Facility's policy titled: Routine Cleaning and Disinfection : Hand Hygiene read in part .hand washing, antiseptic hand wash and alcohol-based hand rubs. Record review of the Facility In-Service Training Report on Infection Control and Handwashing dated 4/18/2023 revealed: Nursing, Housekeeping, and Dietary presented for training. According to the FDA Food Code 2022 dated January 18, 2023 Chapter 3: Food: 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD According to the FDA Food Code 2022 dated January 18, 2023 Chapter 3: Food: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. According to the FDA Food Code 2022 dated January 18, 2023 Chapter 2: Management and Personnel: .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: read in part .(E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; read in part .H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 15 of 15