Inspection·May 11, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some inflammation to the liver), type 2 diabetes mellitus with hyperglycemia (elevated blood glucose level), hypertensive heart disease with heart failure (heart condition caused by high blood pressure), and chronic ischemic heart disease unspecified (heart problems caused by narrowing heart arteries). Record review of Resident #210's baseline care plan, dated 05/02/2023, revealed Section II. Social Services was incomplete. Resident #212 Record review of Resident #212's face sheet dated 05/11/2023, revealed a [AGE] year-old male with an admit date of 05/02/2023. Diagnoses included encounter for orthopedic aftercare following surgical amputation (removal of limb), acquired absence of left foot, type 2 diabetes mellitus with hyperglycemia (elevated blood glucose level), hypertensive heart disease without heart failure (heart condition caused by high blood pressure), and unspecified atrial fibrillation (irregular heart rhythm). Record review of Resident #212's baseline care plan, dated 05/02/2023 revealed Section II. Social Services was incomplete. CR #93 Record review of CR #93's face sheet dated 05/11/2023, revealed a [AGE] year-old male with an admit date of 03/10/2023 and discharge date of 03/29/2023. Diagnoses included posterior reversible encephalopathy syndrome (condition in which parts of the brain are affected by swelling), muscle weakness generalized, type 2 diabetes mellitus without complications (high blood sugar), alcohol use unspecified with withdrawal unspecified, hypertensive emergency (severe elevation in blood pressure), acute respiratory failure with hypoxia (respiratory failure where the level of oxygen becomes dangerously low), and unspecified abnormalities of gait (walking) and mobility. Record review of CR #93's baseline care plan, dated 03/13/2023, revealed Section II. Social Services was incomplete. During an interview on 05/10/2023 at 10:45 a.m., the Director of Nursing (DON) said the timeframe to have the baseline care plan completed was 24 to 48 hours after the resident was admitted to the facility. He said if it was not completed within the required timeframe, the resident and/or family would not be aware of their baseline care and the evaluations from all the departments at the facility. He said they had a full-time social services assistant who was responsible for completing the social services portion of the baseline care plan. He said the social services portion was usually delayed because she had to see what the resident's discharge plan was. During an interview on 05/10/2023 at 11:30 a.m., the Social Services Assistant said she had been working at the facility for over 2 years. She said she was responsible for completing the social services portion on the baseline care plan. She said the timeframe to have the baseline care plan completed was 24 to 48 hours after the resident was admitted to the facility. Record review of the facility's Care Plans - Baseline undated, read in part: Statement A baseline plan of care should be developed for each resident within forty-eight (48) hours of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676435 If continuation sheet Page 2 of 6 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 676435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Transitional Care 8550 Jason Street Houston, TX 77074 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 0655 admission Level of Harm - Minimal harm or potential for actual harm Interpretation and Implementation Residents Affected - Some 1. The baseline care plan should include instructions needed to provide effective person-centered care of the resident which may include the following: a. Initial goals based on admission orders and discussion with the resident representative. b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676435 If continuation sheet Page 3 of 6 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 676435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Transitional Care 8550 Jason Street Houston, TX 77074 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (LVN C) of 1 staff members reviewed for pharmacy services in that: LVN C stored Resident #44's Dorzolamide-Timolol 2-0.5% eye drops in the 2 [NAME] Medication cart uncapped. Resident #44s Dorzolamide-Timolol 2-0.5% eye drops was stored in the 2 [NAME] Medication cart without a cap while not in use. These failures could place residents receiving medications at risk for eye infections. Findings Include: Observation and interview on 5/10/2023 at 11:00 am revealed LVN C administering Dorzolamide-Timolol 2-0.5% eye drops to Resident #44's left and right eye. LVN C did not recap the eyedrop bottle. LVN C placed the opened eyedrop bottle in a pill bottle to store it in the 2 [NAME] medication cart. After Surveyor intervention, LVN C said if eye drops were not recapped, residents were at risk of getting bacteria leading to eye infections. She said the nursing staff were expected to recap eyedrops properly, using the cap to avoid cross-contamination when eyedrops were not in use. She said if eyedrop bottles were not recapped, the process was to order new eyedrops from the pharmacy. She said the inside of the pill bottle was contaminated so she should have recapped the eye drops to prevent contamination. She could not recall the last time she was in-serviced for infection control. In an interview on 5/10/2023 at 11:28 am with the DON, he said the expectation for storage of eye drops was to seal the eye drops properly by recapping the bottles. He said nursing staff should never administer eye drops to a resident if they discovered the eye drop bottle was not sealed properly with the cap being on because residents could get eye infections. He said the nursing staff were expected to seal eye drops properly, using the cap to avoid cross-contamination when eye drops were not in use. He said the expectation for storing eye drops was to date and recap the bottles. He said if there was no cap on eye drop bottles, the nursing staff were supposed to order new eye drops from the pharmacy. The DON said the nursing staff had been in-serviced for infection control in the month of May 2023. This Surveyor asked the DON why the failure occurred; he looked down. The DON had no response. Record review of facilities policy titled; Instillation of Eye Drops read in part . Recap the medication bottle . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676435 If continuation sheet Page 4 of 6 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 676435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Transitional Care 8550 Jason Street Houston, TX 77074 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 observation, interview, and records reviewed, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen, reviewed for proper ice scoop storage in that: -The ice machine scoop was not stored in a covered container. This failure could place residents at risk for cross contamination and food-borne illness. Observation on 05/09/2023 at 3:45 p.m. revealed the ice machine scoop was being stored, uncovered, on the side of the ice machine. During an interview with the Dietary Manager on 05/09/2023 at 3:46 p.m., he said the ice scoop should be stored in an enclosed container. He said the container fell and broke last month. Record review of the facility's Ice Machines and Ice Storage revised date January 2012, read in part: Policy Statement: Ice machines and ice storage distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy interpretation and implementation 2. To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: e. Keep the ice scoop/bin in a container when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676435 If continuation sheet Page 5 of 6 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 676435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Houston Transitional Care 8550 Jason Street Houston, TX 77074 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to dispose of garbage and refuse properly for 1 of 1 waste receptacle reviewed for garbage disposal. Residents Affected - Few -The one dumpster contained waste and its two side doors were left open. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents. Findings included: Observation on 05/09/2023 at 6:45 a.m. with the [NAME] revealed the dumpster's two side doors were open. Observation on 05/09/2023 at 3:40 p.m. with the Dietary Manager revealed the dumpster's side door was open. During an interview on 05/09/2023 at 6:46 a.m. the Cook, stated both side doors were left opened. She said the doors should always be closed. During an interview on 05/09/2023 at 3:41 p.m., the Dietary Manager stated one of two side doors was left opened. He said it should have been closed. Record review of the facility's Food-Related Garbage and Refuse Disposal revised date October 2017, read in part: Policy Statement: Food-related garbage and refuse are disposed of in accordance with current state laws. Policy interpretation and implementation 2. All garbage and refuse containers are provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676435 If continuation sheet Page 6 of 6