Inspection·April 28, 2023

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review [DATE] 1:00p.m. of SBAR completed by LVN A revealed the CR#1 had symptoms of bleeding, GI bleeding and abdominal pain. Vitals signs were taken after the change in condition occurred. BP taken at 8:23 pm, and Pulse was taken at 8:23 pm, and respirations were taken at 8:51 pm and temp was taken at 8:52 p.m. Record review on [DATE] of EMS report revealed on [DATE] they were dispatched to the facility after 911 call was made at 10:18 p.m. Upon arriving at the facility there was found with a significant amount blood in garbage bags, on linens, and covering CR#1. The onset of symptoms was [DATE] at 7:00 p.m. per the staff at the facility. Facility staff was advised that the situation was critical. The facility staff was in the way and delaying scene time. CR #1 was showing signs of clinical worsening. Interview [DATE] 12:15p.m. with LVN A, she said she was the nurse who was with CR#1 the night she went to the hospital. She come in at 6p.m. on [DATE], she made her rounds and check all her patients. At about 7:00pm she normally does her breathing treatments. CR#1 is one of the patients she gave the breathing treatment to. Then she went back to the nurse's station and at about 7:45pm. CNA B came to tell her CR#1 was vomiting blood and had blood in her stool and urine. CNA B said it was a lot of blood gushing out in clots and she was vomiting. When CNA B and LVN A turned her, the bed was covered in blood coming from CR#1's brief. LVN A stated she went to the room and saw CR#1 vomiting blood, there was a substantial amount of blood on the bed and on the resident. LVN A said she stepped out of the room and immediately called EMS. Then she went back into the room took her vitals and help to make sure she was ok until EMS arrived. LVN A said that she must have documented the incorrect time because she said for sure CR#1 had change of condition at around 7:45pm and not 10:45pm. LVN A said she called EMS at about 7:45 then she called the family member, then she called the physician. This process happened very rapidly, and she did her documentation of the SBAR when she returned to work on [DATE]. In another interview LVN A stated she made a mistake and documented the wrong times. She completed breathing treatments around 7pm for CR#1, and then stated that she called EMS at 10:18 pm. LVN A was asked about the delay in calling EMS. LVN A said she had made a mistake with the time. LVN A did not find CR#1 at 740p.m., it was at 10:17p.m Interview [DATE] at 10:47a.m. with CNA B she said she worked with CR#1, on [DATE] and she did not want anybody to touch her. She had to have help to change her most of the time. CR#1 always complained of pain in her lower back. CNA B said she is the one who alerted LVN A the nurse for CR#1 's change of condition. CNA B said it was a lot of blood gushing out in clots and she was vomiting. When LVN A and CNA B turned her, the bed was covered in blood coming from CR#1's brief. CNA B said CR#1 was vomiting blood and urinating and stool with blood she reported this to the nurse on duty. The nurse called EMS and she believes LVN A reported the change of condition to her doctor and family. She does not remember the exact time; she said it was evening. Interview with CR#1's Family member on [DATE] 7:45am, he said he visited CR#1 on [DATE], and she was doing just fine. CR #1 was talking and had been experiencing pain in her back and hip. CR#1 complaining that the facility was not giving her the pain medications she needed. CR#1 left the facility at about 3:00pm and she was just fine. On [DATE] at 1:33a.m. he got a call from the facility that CR#1 was being rushed to the hospital. CR#1's relative got a call from the hospital that she was suffering from internal bleeding and was on life support. He rushed to the hospital and CR #1 never woke up again. Interview [DATE] at 1:56p.m. with the VP of Clinical operations explained that LVN A made an error in documentation. VP of Clinical operations says LVN A called her at 10:18p.m. and advised her of CR#1 Change of Condition and EMS was going to be called. The VP of Clinical operations stated that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676384 If continuation sheet Page 2 of 8 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 676384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Sugar Land, LLC 1803 Wescott Avenue Sugar Land, TX 77479 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few LVN A was not made aware of CR #1's change of condition prior to this time. She explained that LVN A made an honest mistake in her documentation of the time. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:45p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. Plan of Removal The Medical Resort Sugarland [DATE] Immediate Actions taken By Medical Resort Sugarland. Immediate Jeopardy was identified to The Medical Resort Sugarland on [DATE] @ 12:45pm: Quality of Care, F-684. The Medical Resort Sugarland Immediate Jeopardy was called: The Facility failed to ensure that CR #1 received treatment and care in accordance with professional standards of practice. ¢ 100% of all patients admitted to The Medical Resort Sugarland were assessed by Charge Nurses for change in conditions. This assessment was documented and completed on [DATE]. On [DATE] one family member out of 22 current residents stated that she was a little concerned about her husband's appetite and wanted him checked out. [NAME] President of Clinical Services and charge nurses assessed patient and sent out to hospital per family request. Change in condition and transfer form completed. Observed charge nurse give report to EMS, accurate detailed report given by Medical Resort Sugarland Charge Nurse. ¢ LVN A was educated on how to recognize a change in condition, when to notify the physician and the family. LVN A was also educated on the importance of documenting the correct date and time when making a Late Entry. LVN A was also educated on the importance of giving EMS an accurate report on a patient when being transferred to the hospital. Training was provided by the [NAME] President of Clinical Operations on [DATE]. ¢ Change in Condition Policy and Procedure was reviewed by The [NAME] President of Clinical Operations on [DATE]. No revisions to the policy were warranted at this time. ¢ Training on Change in Condition (SBAR) documentation was given to Charge Nurses. Charge Nurses and floor nurses were educated on the importance of documenting real time and also how to document a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676384 If continuation sheet Page 3 of 8 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 676384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Sugar Land, LLC 1803 Wescott Avenue Sugar Land, TX 77479 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few late entry, with emphasis placed on the importance of documenting the correct date and time of the actual event. Training was provided by the [NAME] President of Clinical Operations on [DATE]. ¢ On [DATE] The [NAME] President of Clinical Operations rounded with both the Medical Resort Sugarland ADON and the Charge Nurses and received a verbal report on 100% of all residents admitted to The Medical Resort Sugarland. In addition to [NAME] President rounding with charge nurses, [NAME] President of Clinical Operations delegated to ADON to call 100% of all patient's responsible parties and informed them that when visiting their loved one, please notify the charge nurse immediately if they noticed any changes in the physical or mental status. On [DATE] one family member out of 22 current residents stated that she was a little concerned about her husband's appetite and wanted him checked out. [NAME] President of Clinical Services and charge nurses assessed patient and sent out to hospital per family request. Change in condition and transfer form completed. Observed charge nurse give report to EMS, accurate detailed report given by Medical Resort Sugarland Charge Nurse. Resident was transferred out on [DATE]. ¢ Vice President of Clinical Operations delegated to ADON call 100% of all families to educate them on changes in condition. Informed them that when visiting their loved one, if they noticed a change in their mental or physical status, to please immediately let the charge nurse know so that immediate actions could be taken by the nurse doing an immediate assessment and notifying the physician for further orders. Initiated and completed on [DATE]. ¢ 100% of all Medical Resort Sugarland Staff, including all nursing and non-nursing staff, were in-service on how to recognize a change in condition by [NAME] President of Clinical Operations. For non-nursing staff, [NAME] President of Clinical Operations verbally went over what to do in the event they noticed a resident with a change and gave examples of what a change could reflect to them. All staff were asked questions and were able to verbalize the answers to the group in real time. [NAME] President of Clinical Operations initiated facility wide campaign Change in Condition is Everyone's Responsibility! Campaign will be continued by [NAME] President of Clinical Service and designee to walk the halls in real time and ask questions to all staff, both clinical and non-clinical while observing current patients under the care of The Medical Resort Sugarland. Non-clinical staff were able to verbalize some examples of changes, and what and who to report those changes to. All Medical Staff were re-educated on how to recognize a change in condition and what steps are actively taken when a change in condition is identified such as performing an assessment, notifying the physician and follow up. This was initiated and completed on [DATE]. Training and observation will be ongoing. All clinical staff will be required to complete this in-service before they are able to work in their designated positions. Facilities Plan to Ensure Compliance Quickly ¢ Impromptu QAPI was held [DATE] with the Medical Director and informed him of the two immediate jeopardies that The Medical Resort Sugarland obtained for Quality of Care, F-684 and Notify Physician of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676384 If continuation sheet Page 4 of 8 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 676384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Sugar Land, LLC 1803 Wescott Avenue Sugar Land, TX 77479 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Change in Condition, F-580. Informed the Medical Director that training on Changes in Conditions, SBAR documentation, Late Entry Documentation was given to all clinical and non-clinical staff. Notifications to the families about recognizing and reporting any mental or physical changes noted to their loved ones. No additional guidance at this time. ¢ Residents Affected - Few An in-service was provided to all clinical staff by the [NAME] President of Clinical Operations regarding Change in Condition and Physician/Family notification. The attending physician should be notified as soon as safely possible when a resident change of condition occurs. In the event the resident experiences a medical emergency which requires activation of emergency medical services the attending physician and family would be notified immediately after the transfer of care has been made to emergency medical services personnel. In a non-emergent change of condition, the nurse would initiate an SBAR (as appropriate) and contact the attending physician for further guidance as the condition/situation warrants. The family would be notified within 24 hours of a non-emergent change in condition. The nurse would complete the SBAR documentation, document all events, physician guidance and include information in the shift-to-shift report for continuity of care/follow up. The in-service was initiated and completed on [DATE]. ¢ All Staff will be educated on Policy for Changes in Condition, by the [NAME] President of Clinical Operations and/or designee, which includes when to notify the physician and/or a nurse, BEFORE they are able to work in their designated positions. Monitoring of the plan of removal included: The IJ was called on [DATE] at 12:26p.m. Facility was monitored from [DATE] through [DATE]. The plan of removal was accepted on [DATE]. The IJ was lowered [DATE] at 9:04a.m. with the ED of the facility. Record review of Employee Discipline Notice dated [DATE] revealed LVN A was disciplined for failure to report to the physician the change of condition and failure to call 911 upon seeing the change of condition of CR #1 on [DATE]. Record Review of In-service conducted dated [DATE] The VP and ADON conducted training of all staff on change of condition and reporting of change of condition. The training also included SBAR, physician notification and late entries in the nurses' notes. Interviews were conducted on [DATE] through [DATE] on all shifts with the VP, ADON, LVN A, LVN K, CNA B, CNA C, CNA D, CNA F, and CNA G to verify the in-services had been conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. Record Review QAPI was held [DATE] with the Medical Director and informed him of the two immediate jeopardies that The Medical Resort Sugarland obtained for Quality of Care, F-684 and Notify Physician of Change in Condition, F-580. Informed the Medical Director that training on Changes in Conditions, SBAR documentation, Late Entry Documentation was given to all clinical and non-clinical staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676384 If continuation sheet Page 5 of 8 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 676384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Sugar Land, LLC 1803 Wescott Avenue Sugar Land, TX 77479 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Notifications to the families about recognizing and reporting any mental or physical changes noted to their loved ones. No additional guidance currently. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:45p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. Event ID: Facility ID: 676384 If continuation sheet Page 6 of 8 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 676384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Sugar Land, LLC 1803 Wescott Avenue Sugar Land, TX 77479 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 interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one (CR #2) of two residents reviewed for respiratory care. Residents Affected - Few 1. The facility failed to ensure that CR #2 had tracheostomy care orders in his chart. 2. The facility failed to ensure care/assessment/ intervention for CR#2's tracheostomy was being documented. These failures could place residents who use respiratory equipment at risk for respiratory distress. Findings include: Review of CR #2's face sheet revealed a [AGE] years old male admitted to the facility on [DATE]. His diagnoses included respiratory failure, hyperlipidemia (too much cholesterol or lipids in the blood), end stage renal disease, tracheostomy, anemia, heart disease, heart failure, pneumonia (infection in both lungs), pleural effusion, hepatic (liver) failure, and embolism and thrombosis. Review of CR #2's Physician Order revealed there was no tracheostomy care order for CR #2 and there was no documentation of tracheostomy care for CR#2 during the period of his admission to the facility on [DATE]th, 2022, through [DATE]th, 2023, when CR #2 died. Review of CR#2's MDS dated [DATE], section I8000 D revealed resident had tracheostomy; section O0100 revealed respiratory treatment included oxygen therapy, suctioning, and tracheostomy care. Review of CR #2's TAR (Treatment Administration Record) for [DATE] and [DATE] revealed there was no care documented for CR #2' tracheostomy during the period [DATE]th, 2022, through [DATE]th 2023. Surveyor was unable to ascertain the last time CR #2 had trach care/assessment, and unable to verify if trach care were being provided to CR#2 during the period between [DATE]th, 2022, and [DATE]th 2023. On [DATE] at 1:00 PM in an interview with RN A, she stated she had been working at the facility over a month and did not know this patient. She stated when she did trach care she would document into the Treatment Administration Record for the patient. She stated when she was hired at the facility, she went through hands-on training on trach care and the expectation was that nurses were required to always record every care provided to residents in their records and if there was no order, nurse should call the doctor for order. On [DATE] at 2:13 PM in an interview with LVN B, she stated she just started working at the facility and today ([DATE]) was her second day on the job. She stated she was trained on trach care on her first day of work at the facility. She stated she performed trach care for the resident assigned to her today ([DATE]) and she documented into the TAR as this was the expectation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676384 If continuation sheet Page 7 of 8 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 676384 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Sugar Land, LLC 1803 Wescott Avenue Sugar Land, TX 77479 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 On [DATE] at 2:38 PM in an interview with the Former ADON, she stated she was employed by the facility at end of [DATE]. She stated she discovered there were some residents whose order were not update or incomplete. She stated she started chart audit because the failure could affect residents care resulting in missed or incomplete record. she said unfortunately she was unable to audit all the residents in the facility including CR#2 before she left. She also stated she had conducted in-service for the nurses working with her at that time. On [DATE] at 2:58 PM in an interview with the VP of Clinical Operation, she stated the expectation was for all nurses to make sure resident has order and document all treatments in the TAR. She stated she did not understand what happened to CR#2's trach care orders and TAR. She stated nurses were supposed to always document trach are for CR#2 and other residents, and if there was no order, they were expected to call Doctor for orders. Record review of the policy titled 'Tracheostomy Care' dated February 2014 reads, in part, document the procedure, condition of the site, and the resident's response FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676384 If continuation sheet Page 8 of 8