Inspection·August 1, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of CR #1's MAR for June 2024 and July 2024 did not reveal that CR #1's was administered the medication gentamicin IV. Record review of CR #1's Discharge Summary revealed that CR #1 discharged from the NF on 07/03/2024. Observation on 07/30/2024 at 10:32AM the door to the medication room was open. Further observation was made of a trash can up against the door. In an interview on 07/30/2024 at 10:32AM with RN A, she said the door to the medication room should always be closed to prevent someone from taking medications out of the medication room who did not have authorization. RN A closed the door to the medication room. Observation on 07/30/2024 at 10:42AM of the medication room fridge was a 100ml bag of normal saline. The bag was labeled with CR #1's name reading gentamicin 140mg. The expiration on the bag was 03/29/2024. Further observation inside the bottom drawer of the fridge was two clear plastic containers with food inside of them. Further observation was made in the medication room sitting on top of the counter were7 bottles of gastrostomy feedings labeled Glucerna 1.5 cal 22.8 fld oz . The expiration on the bottles read June 1st, 2024. In an interview on 07/30/2024 at 10:45 AM with RN A, she said food should not be placed inside of the fridge in the medication room but inside of the fridge in the employee break room. RN A said everyone should be checking the medication room for any expired medications. RN A said the NF had one medication room. RN A said CR #1 had discharged from the NF . Observation on 07/31/2024 at 8:37AM the door to the medication room was wide open while RN B was sitting at the nurse's station. Observation on 07/31/2024 at 8:45AM of the DON standing in the hallway by the nurse's station. The door to the medication room remained open. The DON walked away from the nurse's station toward hall 100. Observation on 07/31/2024 at 8:50AM the door to the medication room remained open with RN B sitting at the nurse's station on the computer. RN B then left the nurse's station walking down Hall 200. There was no one at the nurse's station. There was a sign on the medication door reading Nurses and medication aides allowed only!!! Door must remain closed at all times. In an interview on 07/31/2024 at 9:37AM with RN B, she said she had been working at the NF for almost 6 months, full time 6am-6pm. RN B said the door to the medication room was supposed to be closed at all times to prevent someone who was unauthorized from entering into the medication room. RN B said it must have been an oversite on her part to leave the door open. In an interview on 07/31/2024 at 10:05AM with the DON, she said the door to the medication room should be closed at all times because of medications being inside of the room. The DON said the medication room had a machine called a Nexis inside of the room that housed medications that included narcotics. The DON said in order to access the Nexis one had to be given a log in with a password. The DON said it was herself and the nurses on the unit that were supposed to check the medication room for any expired medications or feedings. The DON said no food was supposed to be stored inside the fridge in the medication room for sanitation and infection control reasons. The DON said it must have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 2 of 5 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 08/01/2024 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 0755 been the nurses on the night shift that had done this . Level of Harm - Minimal harm or potential for actual harm In an interview on 08/01/2024 at 1:58PM with the pharmacist via phone, she said when she came to the NF. Her job duties included the following: drug regimen reviews, drug destruction, and checking for any expired medications. The pharmacist said she was last at the facility in July of 2024. The pharmacist said it was important to check for expired medications to promote safety for the residents. Residents Affected - Some Record review of the NF policy on Medication Storage with a copy right 2024 revealed in part: .t is the policy of this facility to ensure all medications housed on the premises will be stored in the pharmacy and /or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, and ventilation .only authorized personnel will have access to the keys to locked compartments . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 3 of 5 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 08/01/2024 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were discarded. 2. The facility failed to ensure foods were dated as opened/preparation discarded after 96 hours. 3. The facility failed to keep food off the floor. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 07/30/24 at 8:15 AM revealed the following. 1. 2 Quarts of High Protein Supplement Drink in the walk-in cooler with a manufacturer expiration date of 5/21/24. 2. A Plastic container of Chocolate Pudding in the walk-in cooler with a used by date 7/27/24. 3. A Plastic container of Cream of Mushroom Soup in the walk-in cooler with a used by date 7/24/24 4. A Plastic container of Chicken Gravy in the walk-in cooler with a used by date 7/24/24 5. A Plastic container of Spaghetti Sauce in the walk-in cooler with a used by date 7/23/24 6. 2 cs. of Frozen Orange Juice in the walk-in freezer stored on the floor. 7. 1cs. Of frozen Okra in the walk-in freezer stored on the floor. In an interview with the Dietary Food Service Manager on 07/30/24 at 10:25 AM; she stated the leftover food stored in the refrigerator should have been used or discarded prior to the use by date; she stated that the Cases of food should be off the floor. She said that she would be re-in-service dietary staff on labeling and dating the food. She said that the tray aides were responsible for checking the food in the cooler/freezer and to discard food prior to the used by date. Record review of the facility's policies and procedures for Food Safety dated 04/2024 read in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 4 of 5 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 08/01/2024 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 immediately. They are discarded after 96 hours unless otherwise indicated. For food storage keep off floor. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676334 If continuation sheet Page 5 of 5