Health inspection·January 22, 2024

F 0580 Level of Harm - Immediate jeopardy to resident health or safety [Resident #4] was on oxygen therapy related to shortness of breath, dyspnea, and heart failure ,,, Goal: [Resident #4] will have no signs and symptoms of poor oxygen absorption through the review period . Approach: Monitor, document, and report signs and symptoms of respiratory distress such as; (r)espirations, pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (collapse of part or all of lung), hemoptysis (coughing up blood), cough, accessory muscle usage, and skin color . Residents Affected - Few Record review of vitals [last documented]: [DATE] [7:11 am] Pulse: 81 [DATE] [7:11 am] BP: 110/80 mmHg [DATE] [9:03 am] Respiration: 18 per minute [DATE] [9:03 am] Oxygen Saturation: 92% Record review of progress note dated [DATE] [6:20 am] revealed: Upon nursing rounds patient noted with abnormal breathing. Checked sats at this time and noted to be 85%. NC in place, no kinks observed, O2 water bottle, and NC replaced. Patient repositioned, HOB elevated. Floor nurse at bedside monitoring O2 level. Level up to 92% with O2 at this time. Patient breathing pattern stabilized. Call light in reach, bed in low position. CNA staff informed by floor nurse to monitor/check on patient regularly. Will continue to monitor. Interview on [DATE] at 12:13pm with the DON , she said a change in condition is a change from resident's normal or baseline. She said nurses are expected to report changes in condition to the primary provider (doctor) in case the doctor would need to make changes to an order or has another recommendation. She said failure to notify can cause a delay or inadequate treatment . Interview on [DATE] at 1:03pm with MD Z, he said he was unaware that Resident #4 was having difficulty with his oxygen levels the morning of [DATE]. He said the only call that he remembered from nursing staff was to tell him that they had to call 911 for Resident #4 . Interview with LVN K on [DATE] at 1:12 pm, she said she never had a set % oxygen saturation level to which she was instructed to call the doctor if it reached that level. She said the morning of [DATE], she was in and out of the room every 15 minutes checking on the resident after his morning episode of low oxygen. She said she could not recall whether or not she called the doctor to notify him of resident's low oxygen experienced that morning [[DATE] at 6:20am Oxygen sat 85%]. She said she called EMS around 9:00 am because he just didn't look good, and she contacted the resident's doctor, and RP at that time. She said the doctor should be notified of change in conditions so they know what it is happening and can adjust treatment or make a recommendation. She said in this instance, she was closely monitoring the resident and the resident seemed to be doing okay . Interview on [DATE] at 1:40 pm with the Administrator, she said that she started at the facility on [DATE] and had no prior knowledge of the circumstances surrounding the death of Resident #4. She said her expectation would be for nursing staff to, at minimum, document by exception meaning that anything that is outside of a resident's normal should be documented and the physician notified. She said the failure to notify physician of change in condition can result in the resident not getting the appropriate care and possible decline. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 2 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0580 Record review of Change in Resident's Condition or Status Policy (2021) revealed: Level of Harm - Immediate jeopardy to resident health or safety Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Residents Affected - Few 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition . i. specific instruction to notify the physician of changes in the resident's condition . 2. A significant change of condition is a major decline or improvement in the resident's status that: . q. will not normally resolve itself without intervention by staff . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact SBAR communication Form. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:00 pm The Administrator, the DON, the Assisting Administrator, and the CNC were notified. The administrator was provided with the IJ template via email on [DATE] at 2:17 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:55 pm: The Texas Department of Health and Human Services entered Windsor Houston on [DATE], for a follow up on a Complaint Survey on a P1 that initiated on [DATE]. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F580 as stated below: In-which resident #4 was transferred from facility to ER via EMS where he expired. Plan of Removal: F580 All direct care nursing staff will be in-serviced on the followingThe expectation for all direct care nursing staff is to identify and document all change of conditions with the proper notifications to the MD, the RP, the DON, and the Administrator. The facility DON/ADON/Designee notified all direct care nursing staff of facility's policies regarding notifications, change of condition, reporting, and abuse and neglect. All direct care nursing staff will demonstrate and acknowledge that they are aware of how to identify a change of condition, how to complete an SBAR, and how to initiate the proper notifications. Specifically, where to locate the resident's medical history, to ensure they are capturing and can identify a change of condition to then have the proper documentation, and notifications in place. To access the employee will log into MatrixCare, select resident, then search resident by name, then select resident progress notes, residents face sheet for medical diagnosis, residents care plan, residents' orders, resident's vitals, and resident's observations/events, and residents' orders, to ensure the nursing staff member is familiar with the resident's baseline and level of care. The DON and designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding documentation, notifications, change in condition, and abuse and neglect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 3 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0580 Level of Harm - Immediate jeopardy to resident health or safety The training regarding identification of change of conditions and proper notifications will be an ongoing continuous training to be conducted quarterly with the first training completed [DATE]. Training will also be included in the new hire process for all direct care nursing staff which will include a skills competency. The DON/ADON during morning start-up will ensure that all change of conditions are captured with an SBAR along with the proper notifications. Residents Affected - Few The training confirmations will be stored with their employee file in the Human Resources department. This is to include all direct care nursing staff and those with CPR certifications to cover the topics of: Importance of/and expectation that all licensed nursing staff will identify, and document all change of conditions with the proper notifications to the MD, the RP, the DON, and the Administrator promptly. The DON/ DON Designee will contact all direct care nursing staff to obtain signatures on site or via Facetime with acknowledgment, however, if unable to obtain face to face a verbal acknowledgement will be obtained along with 2 signatures by the DON/DON Designee to serve as an understanding of what the expectation is for all direct care nursing staff to identify and document all change of conditions with the proper notifications to the MD, the RP, the DON, and the Administrator promptly. On [DATE], the facility Administrator and the Director of Nursing notified Medical Director via phone. Items discussed were: IJ (Immediate Jeopardy) was cited on [DATE] as evidenced by facility's failure to:

F580- Effective [DATE] the DON/ ADON/ designee will randomly observe direct care nursing staff demonstrate how to identify change of condition and when to do the proper notifications to the MD, the RP, the DON, and the Administrator. The DON/ADON/designee will conduct random observations with all direct care nursing staff of their ability to identify a change of condition and when to do the proper notifications to the MD, the RP, the DON, and the Administrator. All direct care nursing staff were contacted in person or by phone and verbally in-serviced. All direct care nursing staff in-services will be completed by 10:30AM on [DATE]. All direct care nursing staff will be made aware and provided with a copy of the facility's policies regarding change of condition, notifications, reporting, and abuse and neglect. The DON/ADON/designee completed a 100% audit of all Change of Conditions since [DATE] to ensure that the MD/RP was notified and documentation was in the resident's medical records . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 4 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0580 Monitoring: Level of Harm - Immediate jeopardy to resident health or safety Record review of CPR certifications on [DATE] for all nursing staff listed, reflected all CPR certifications for nursing staff in report to be current. Residents Affected - Few Record review of in-service trainings provided to direct care staff (licensed nurses) and other facility staff in contact with residents as part of the Plan of Removal. The following policies and protocols were reviewed: CPR on soft surfaces; Emergency Cart Checklist; AED, CPR, SBAR, Documentation, Notifying the MD, the RP, the DON, and the Admin; Stop & Watch, Abuse, Neglect, Exploitation, and Residents' Rights, Matrixcare Information, Mock Demonstration of Code Blue (CPR); Vital Signs return demonstration; CPR, Crash cart/Backboard. Interviewed 10 nurses across the three shifts who were able to verbally demonstrate knowledge gained from in-services. Interviewed 7 CNAs, 2 housekeepers, and 1 therapist who were able to verbally demonstrate knowledge gained from in-services. The Administrator, assisting Administrator, DON, and CNC were informed the Immediate Jeopardy was removed on [DATE] at 6:17 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate threat and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 5 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 2 out of 12 residents (Resident #1 and Resident #2) reviewed for comprehensive care plans. -The facility failed to ensure Resident #1 and Resident #2 had a code status that was care planned. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life. Findings included: Resident #1 Record review of Resident #1's undated face sheet revealed she was an [AGE] year-old female admitted on [DATE], with diagnoses of respiratory failure (not having enough oxygen), cognitive communication deficit (trouble communicating), muscle wasting and atrophy, shortness of breath, high blood pressure, and chronic obstructive pulmonary disease (chronic lung disease that makes it hard to breathe). Her face sheet said Full Code. Record review of Resident #1's admission MDS assessment dated [DATE], revealed a BIMS score of 11 out of 15 which indicated moderate impairment of cognition. She required substantial/max assistance with toileting, showers/baths, upper/lower body dressing, and putting on/taking off footwear. She was always incontinent of bowel and bladder and used a walker for mobility. Record review of Resident #1's undated care plan with a revision date of [DATE], did not have a code status care planned. Record review of Resident #1's Physician Orders revealed an order for Code Status: Full Code, ordered on [DATE] at 8:20 pm by MD A. Record review of the facility's Code Book kept on the crash cart on [DATE] at 1:55 pm, revealed Resident #1's code status was correct in the book. Resident #2 Record review of Resident #2's undated face sheet revealed he was an [AGE] year old male admitted on [DATE] with diagnoses of congestive heart failure (heart is unable to pump fluid out of lungs), type 2 diabetes (body does not produce insulin or is resistant to it), dementia, high blood pressure, myocardial infarction (heart attack), atherosclerotic heart disease (plaque in the arteries of the heart), and lack of coordination. The face sheet said Full Code. Record review of Resident #2's admission MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severely impaired cognition. The resident was substantial/mas assist with toileting, showers/baths, lower body dressing, and putting on/taking off footwear. He was always (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 6 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0656 incontinent of bowel and bladder and used a wheelchair. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's undated care plan with a revision date of [DATE], did not have a code status care planned. Residents Affected - Some Record review of Resident #2's Physician Orders revealed an order for Code Status: Full Code, ordered on [DATE] at 1:07 am by MD B. Record review of the facility's Code Book kept on the crash cart on [DATE] at 1:55 pm, revealed Resident #2's code status was correct in the book. Interview with the ADON on [DATE] at 3:35 pm, she said one of the most important things to have on a care plan was the resident's code status because staff needed to know what the resident wanted if something happened to them. She said if the care plan did not have the code status the facility could perform the wrong code and get in trouble if it was not what the resident wished for. She said they had a code book on the crash cart that staff usually looked at though in an emergency. She said she was the one in charge of updating the code book from the physician orders in the chart. Interview with LVN A on [DATE] at 3:53 pm, she said the code status was the most important thing to have on a care plan. She said it could affect the resident because if they were a Do Not Resuscitate (DNR) and staff performed CPR the facility would be in trouble. She said the nurses were the ones who updated the care plans with the code status when the resident was admitted to the facility. Interview with the DON on [DATE] at 4:15 pm, she said the nurses were the ones who updated the code status on the care plans when the resident arrived at the facility. She said the MDS Nurse also updated some of the care plans, but mainly the nurse updated the code status. She was not sure why the code statuses were not updated. Record review of the facility's policy and procedure on Care Plans, Comprehensive Person-Centered (revised [DATE]) read in part: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment .and no more than 21 days after admission .The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 7 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 of 1 resident (Resident #4) reviewed for basic life support, including CPR. -The facility failed to retrieve the automatic external defibrillator (AED) and initiate the basic life support sequence of events (chest compressions, airway, breathing) per the facility's Emergency ProcedureCardiopulmonary Resuscitation Policy (CPR) for Resident #4. On [DATE] at 2:00 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 6:12 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place all residents who requested a full code status at risk of not receiving necessary life-saving measures, declining health, and death. Findings include: Record review of Resident#4's face sheet dated [DATE] revealed he was an [AGE] year-old male admitted on [DATE] and readmitted from the hospital on [DATE]. The face sheet listed relevant diagnoses which included: Acute and Chronic Respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), Hemiplegia (paralysis on one side of the body) following stroke (damage to brain from interruption of blood supply), Presence of a Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly), Atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart), Atrial Fibrillation (condition in which the heart's upper chambers beat chaotically and irregularly), and Hypertension (elevated blood pressure). Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed he had a BIMS score of4, indicating severe cognitive impairment. Record review of Acknowledgement of Advance Care Planning dated [DATE] revealed Resident [#4] was full code status. Record review of Care Plan (undated) revealed: . [Resident #4] was full code [[DATE]] . Approach: Ensure order entered under advanced directive; Discuss code status and options with resident and family members at routine intervals as needed; Monitor for changes in condition and status and promptly report to MD . Emergency transport to hospital as indicated; Have crash cart ready; If resident found without a pulse, have someone call 911, send other nursing staff to assist with code, send crash cart to location of code, and notify the MD and the DON or designee of code being performed. Record review of vitals [last documented]: [DATE] [7:11 am] Pulse: 81 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 8 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0678 [DATE] [7:11 am] BP: 110/80 mmHg Level of Harm - Immediate jeopardy to resident health or safety [DATE] [9:03 am] Respiration: 18 per minute Residents Affected - Few Record review of progress note dated [DATE] [9:10am] by LVN K revealed that Resident #4 was nonresponsive with oxygen saturation of 82%. The resident did not respond to sternal rub. Portable oxygen tank was brought into the room and patient placed on non-rebreather mask at 15 liters. 911 notified. The MD notified and the RP contacted. Floor nurse [LVN K] remained with resident until 911 arrived. Eyes fluttered. [DATE] [9:03 am] Oxygen Saturation: 92% Record review of progress note dated [DATE] [9:18 am] by LVN K revealed 911 here. Patient unable to arouse. CPR initiated by 911 staff. Floor nurse notified (family member) of what's going on. Patient FULL CODE. Record review of EMS Unit Incident Details revealed the call to 911 was received on [DATE] at 9:11 am. EMS arrived to the facility at 9:30am and arrived to the patient [Resident #4] at 9:32 am. EMS left the facility at 9:56 am and arrived at the hospital at 10:08am. The Clinical Info Narrative section revealed: [Resident #4} was found by nurse lying in bed unresponsive and contacted for EMS assistance. [EMS] arrived to find pt unresponsive with absent pulses and absent respirations and no bystander CPR. Pt was moved to the floor and AED protocol administered, I-gel (a medical devices that facilitate oxygenation and ventilation without endotracheal intubation) was established and CPR administered . Pt [Resident #4] was transported to hospital and transferred to ER nurse and pronounced dead. The Special Circumstances revealed date and time of cardiac arrest: [DATE] at 9:06 am. Arrest witnessed by: Other Healthcare Provider. AED use Prior to EMS arrival: Yes, without defibrillation. First monitored Arrest Rhythm of Patient: Unknown AED Shockable Rhythm, Date and Time Last Known Well: [DATE] at 9:03am. Any return of spontaneous circulation: No, Who Initiated CPR: HFD First Responder . Who first applied the AED: HFD First Responder (Eng/Lad). [Resident #4 Pronounced Dead in ED ]. Record review of Hospital ED report revealed CPR in progress upon arrival [[DATE] at 10:08am]. Patient sent from nursing facility, found by nursing staff unresponsive without oxygen. No bystander CPR. EMS unit began CPR at 9:08am. 7 shocks 3 epi (drug used to reverse cardiac arrest) given by EMS. Time of death called at 10:21 am. Record review of Resident #4's certificate of death dated [DATE] revealed immediate cause of death was complications from chronic respiratory failure. Interview on [DATE] at 8:22 am with LVN K, she said she came to check on the resident around 9am on [DATE]. He had been having breathing difficulty that morning, and she said she and an aide were doing 15-minute rounds [no documentation]. She said around 9:00 am, Resident #4 just started to look unwell, and she called 911. She said oxygen levels decreased to 82%. She said resident's doctor and RP was notified. She said Resident #4 was still responsive with a pulse at this time, so she did not initiate CPR. She said EMS arrived in approximately 5-10 minutes. LVN K said she was unsure exactly of when Resident #4's vitals started to decline, but it happened between the time she called 911 and when they arrived. She said that Resident #4 was a large man and she and an aide were in the process of getting him to the floor when EMS arrived. She said that EMS immediately took over upon arrival and started CPR . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 9 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Observed on [DATE] at 1:05 pm, the facility crash cart and AED machine located near the nursing station, adjacent to the dining room. Observed no back board on the crash cart, however, the DON found it between the wall and a different cart parked adjacent to the crash cart [not immediately visible]. Interview on [DATE] at 1:12 pm with LVN K, she said she called EMS because he just did not look good, however, Resident #4 did have a pulse which was why CPR was not initiated at that moment. She said she does not know when he ceased to have a pulse. She said she and CNA H were preparing to lower Resident #4 to the floor in case they had to do CPR. She said by the time they had gotten him down; EMS came in and took over. They immediately started CPR. She said CPR could not be done in the bed because it was not a firm surface . Interview on [DATE] at 1:23 pm with CNA H, she said that on [DATE] she witnessed LVN K frequently checking on Resident #4 through the morning. She said around 9am, LVN K called the ambulance for Resident #4 because he was not looking too good. CNA H said the paramedics arrived quickly. She said Resident #4 was a big man, and it took her and LVN K about 10 minutes to lower the bed and get the resident down to the floor in preparation to begin CPR. She said by the time he was down, the paramedics had already arrived and they took over. CNA H said that she could not say anything about Resident #4's vitals at the time because she did not recall. She said the resident had an air mattress which was why CPR could not be done in the bed. She said she was not familiar with a backboard and did not know the facility had one . Interview on [DATE] at 12:13pm with the DON, she said when a resident codes, whoever was with the resident should call for help and stay with the resident. If the resident was a full code, the resident should be placed on a hard, flat surface while someone else brings the crash cart and AED. Once on, the AED would give instructions and staff would continue CPR until there was a pulse, or 911 arrived, or if the doctor called it and says to stop. She said if the resident was in bed they should be placed on a hard, flat surface. The policy did not specify surface type. She said if the resident were of large stature and in bed, then the resident should have been placed on a backboard. She said failure to implement basic life saving measures could possibly cause harm or death. Interview on [DATE] at 1:03pm with MD Z, he said he was unaware that Resident #4 was having difficulty with his oxygen levels the morning of [DATE]. He said the only call that he remembered from nursing staff was to tell him that they had to call 911 for Resident #4. He said CPR was appropriate if the resident was unresponsive and had no pulse. He was not aware of who implemented CPR for Resident #4. He said he could not say whether or not CPR would have made a difference for Resident #4, but failure to provide CPR in a timely manner could increase likelihood of death. MD Z said the resident has had similar episodes before, a week prior in fact, for which he was sent out to the hospital and returned to the facility. He said that he cannot say what happened differently that lead to Resident #4's death because it could have been that his heart gave out. Interview on [DATE] at 1:40 pm with the Administrator, she said that she started at the facility on [DATE] and had no prior knowledge of the circumstances surrounding the death of Resident #4. She said her expectation would be for nursing staff to, at minimum, document by exception meaning that anything that was outside of a resident's normal should be documented and physician notified. She said if a resident was found unresponsive and without a pulse, a code should be called, and basic life saving measures implemented if the resident was full code. The Administrator said that she spoke to LVN K who told her that she did not start CPR because Resident #4 had a pulse, but there was no documentation, nor could the nurse say when the resident transitioned. She said failure to initiate CPR in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 10 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0678 a timely manner could be detrimental to the resident. Level of Harm - Immediate jeopardy to resident health or safety Record review of Emergency Procedure- Cardiopulmonary Resuscitation (2018) revealed: . 6. If the individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR immediately unless: Residents Affected - Few a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or . b. there are obvious signs of irreversible death (e.g., rigor mortis) Record review of Automatic External Defibrillator, Use and Care of Policy (2015) revealed: . 3. The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected. Recognizing the signs and symptoms of arrhythmia (and when to use the AE) is part of the CPR/BLS training .4. In general, sudden cardiac arrest should be suspected if: a. the victim's symptoms appeared very suddenly; b. he or she is unresponsive; c. his or her breathing has stopped . 5. If an individual is found unconscious and SCA is suspected, begin the AED protocol . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 2:00 pm. The Administrator, the DON, the Assisting Administrator, and the CNC were notified. The Administrator was provided with the IJ template via email on [DATE] at 2:17 pm. The following Plan of Removal submitted by the facility was accepted on [DATE] at 12:55 pm: The Texas Department of Health and Human Services entered Windsor Houston on [DATE], for a follow up on a Complaint Survey on a P1 that initiated on [DATE]. During the survey process an IJ (Immediate Jeopardy) was cited on [DATE] regarding - F678 as stated belowIn-which resident #4 was transferred from facility to ER via EMS where he expired. Immediate Interventions: Plan of Removal: F678 All direct care nursing staff and those with CPR certifications will be in-serviced on the followingThe expectation for all direct care nursing staff is to identify and utilize the crash cart, backboard, AED, how to perform CPR and when to initiate CPR; in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare . In serviced all floor nurses, administrative nurses, CNAs, CMAs, PTs, OTs, and STs on ensuring the resident is on a hard surface if and when CPR is initiated. If the resident is on an air mattress, the air mattress is to be deflated with backboard in place beneath the resident unless the resident is able to be safely be transferred to the floor. All direct care nursing staff will demonstrate and acknowledge that they are aware of how to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 11 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR; in the event a resident is unresponsive with no pulse. Specifically, to locate the code status binder, which is accessible by all direct care nursing staff and indirect care staff in the facility. All direct care nursing staff will demonstrate and acknowledge how to access code status in Matrix. The employee will log into MatrixCare, select resident, d then search resident by name, resident facesheet, resident identifiers and banners, and resident code status. To validate DNR status, the employee will select resident documents, advance directives tab, and look for the advance directive. The DON and designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding identification and utilization of the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR; in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. The training regarding identification and utilization of the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR; in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare will be an ongoing continuous training to be conducted quarterly with first training completed [DATE]. Training will also be included in new hire process for all direct care nursing staff and staff with CPR certification which will include a skills competency. The DON/ADON or Designees during morning start-up will ensure that the backboard is with the crash cart and during the weekends and holidays a designee will ensure that the backboard is with the crash cart. (Backboard is now attached to the crash cart). 100/200 hall nurses will do walking rounds, each shift (6am-2pm, 2pm-10pm, 10pm-6am), to ensure the backboard is in place prior to shift hand-off and will witness on change of shift log that backboard is in place. Nursing to notify the DON for all change of conditions along with MD/RPs. The facility DON/ADON/Designee notified all direct care nursing staff of facility's policies regarding AED, CPR, emergency nursing response, notifications, reporting, and abuse and neglect. The training confirmations will be stored with their employee file in the Human Resources department. On [DATE], the Director of Nursing initiated an addendum to the original in-service initiated on [DATE] to include visual aids and questions to assist staff with identification of the location of the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive without a pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. This is to include all direct care nursing staff and those with CPR certifications to cover the topics of: Importance of/and expectation that all licensed nursing staff and those with CPR certifications will demonstrate and acknowledge that they are aware of where to locate the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 12 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The DON/DON Designee will contact all direct care nursing staff and those with CPR certificate to obtain signature on site or via Facetime with return demonstration and acknowledgment signed off on prior to start of next shift. However, if unable to obtain face to face or visual presentation a verbal acknowledgement will be obtained along with 2 signatures by the DON/DON Designee to serve as a understanding of what the expectations are for all floor nurses, administrative nurses, CNAs, CMAs, PTs, OTs, and STs to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare.

F678-Effective [DATE] the DON/ADON/designee will randomly observe direct care nursing staff demonstrate how to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. The DON/ADON/designee will conduct random observations with all direct care nursing staff of their ability to identify and utilize the crash cart, backboard, AED, how to perform CPR, and when to initiate CPR in the event a resident is unresponsive with no pulse, and how to utilize code status binder located on the crash cart, and via computer utilizing MatrixCare. All direct care nursing staff and those with CPR certifications were contacted in person or by phone and verbally in-serviced. All direct care nursing staff and those with CPR certifications in-services will be completed by 10:30AM [DATE]. All direct care nursing staff and those with CPR certifications will be made aware and provided with a copy of the facility's policies regarding AED, CPR, emergency nursing response, notifications, and reporting, and abuse and neglect. Results of all observations will be reviewed by the Interdisciplinary Team to ensure that proper adherence to this process is met. Any deviations or omissions will be addressed immediately with staff member. This will be reviewed monthly in QAPI until compliance is met. Monitoring: Record review of CPR certifications on [DATE] for all nursing staff listed, reflected all CPR certifications for nursing staff in report to be current. Record review of in-service trainings provided to direct care staff (licensed nurses) and other facility staff in contact with residents as part of the Plan of Removal. The following policies and protocols were reviewed: CPR on soft surfaces; Emergency Cart Checklist; AED, CPR, SBAR, Documentation, Notifying the MD, the RP, the DON, and the Admin; Stop & Watch, Abuse, Neglect, Exploitation, and Residents' Rights, Matrixcare Information, Mock Demonstration of Code Blue (CPR); Vital Signs return demonstration; CPR, Crash cart/Backboard. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676337 If continuation sheet Page 13 of 14 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 676337 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interviewed 10 nurses across the three shifts who were able to verbally demonstrate knowledge gained from in-services. Interviewed 7 CNAs, 2 housekeepers, and 1 therapist who were able to verbally demonstrate knowledge gained from in-services. The Administrator, assisting Administrator, DON, and CNC were informed the Immediate Jeopardy was removed on [DATE] at 6:17 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 676337 If continuation sheet Page 14 of 14