Inspection·July 21, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some complications as evidenced by wound documentation; Approach start date 06/13/25- nurse to complete wound documentation daily, refer to wound care doctor as needed, wound team to evaluate wound(s), treatments and healing status weekly. Problem start date of 06/16/25- CR#1 has trauma to left great toe; Goal target date: 09/16/25- wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained; Approach start date: 06/16/25- CNA to inspect skin, especially over bony prominences, during bathing and personal care. Nurse to complete wound observation weekly. There was no mention of podiatry care or services or her vascular disease.Record review of CR #1's Physician's Orders revealed, Start Date 09/18/24; Description- Consult: Podiatry, Ophthalmology, dental as needed .Record review of CR #1's Progress Notes from admission on [DATE] to discharge on [DATE] revealed, There was no documentation that CR #1 received podiatry care while at the facility with the following relevant entries included:-09/17/24 at 12:45 PM signed by LVN L- resident's skin is warm to touch, dry and no fresh injuries. The resident had an old scar from the above knew amputation. The resident requires assistance with feeding and is total care. -09/19/24 at 07:00 PM signed by Wound Nurse A- New admission skin assessment completed. Patient's skin intact and dry. Patient has a right knee amputation, old scar intact and dry, left lower leg has old scares, left great toe has old scab 0/8X0.5X0.1 cm, no exudate, no pain, no odor or s/sx of infection.-06/12/25 at 11:27 PM signed by LVN D: upon assessment, the resident's left great toes appears bruised. No signs or symptoms of pain noted. Foot pulses were felt, no sign of compromised circulation. Foot is warm and dry to touch.-06/13/25 at 02:06 PM signed by Wound Care Nurse A revealed, nurse informed writer that patients left great toe appears to have bruising, writer assessed and observed a diabetic ulcer to left, great toe 08X0.5cm, no exudate, no odor or s/sx of infection, no pain. cleansed with normal saline, patted dry with sterile gauze, applied skin prep and left open to air. Called and spoke with patient's family and discussed the assessment and plan of care.-06/15/25 at 07:05 AM signed by LVN D- during morning rounds, the aired reported that CR #1's big toe appeared to be bleeding and bruised. Upon assessment, observed active bleeding from the toe, with bruising extending up the foot and lower leg. Resident verbalized pain upon palpation of the affected area. NP notified for further evaluation and management.- 06/15/25 at 07:05 AM signed by LVN D- NP ordered STAT Xray to the affected toe and leg06/16/25 at 05:34 PM signed by Wound Care Nurse B, nurse reported CR #1's left great toe has bruises and bleeding. Upon assessment, noted trauma to left toe measuring 1.2X2X0.1 cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection. NP made aware, wound cleaned with normal saline, pat dry with sterile gauze, applied Bactroban (antibiotic ointment) and covered wound with gauze, procedure tolerated by patient. Requested for podiatry service to the Social Worker-06/16/25 at 05:46 PM signed by RN A- X-ray of the left foot was completed during this shift in response to an existing wound. Resident tolerated the procedure without any complications. Left foot wound remains covered with dressing intact; no signs of active bleeding, or foul odor noted. Awaiting radiology results at this time.-06/16/25 at 06:25 PM signed by RN A- C-ray results were received and reviewed by NP as negative for fracture. -06/17/25 at 04:31 PM signed by Wound Care Nurse A- CR #1 family stopped by the office to ask questions regarding resident wounds, family was informed that patient has a diabetic ulcer to the left great toe and its being treated with skin prep daily and left open to air, trauma to the left great toe and it's being treated with Bactroban and covered with gauze daily, patient has been added to the podiatry list by the Social Worker and the WCD will be rounding on Thursday and will further assess patient's wounds and family will receive a weekly call with an update. Family expressed concerns of patient getting gangrene due to past experience of getting the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 2 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some right leg amputated and wanted to send patient out to get antibiotics. Family educated on the use of Bactroban ointment and informed and no s/sx of infection observed at this time, but Wound Care Nurse A can only give information on the assessment of wounds and the treatments put into place by the WCD via telehealth.06/17/25 at 06:35 PM signed by RN A, CR #1 noted with a diabetic wound to the left foot. During a family visit today[SP2] , the resident's family expressed concern that the foot might be infected and requested that the resident be transported to the emergency room for further evaluation. Upon assessment, no signs or symptoms of infection were noted. Contacted EMS for non-emergency transportation, resident transported to the hospital for further evaluation.Record review of CR #1's Point of Care History from 09/17/24 to 06/17/25 revealed, no documentation of toenail care to CR #1.Record review of CR #1's Shower Sheets from 09/17/24 to 06/17/25 revealed, the only documented nail care was on 05/29/25 and no clarification was made if it was finger or toenail care. Record review of CR #1's Weekly skin Assessments from admission on [DATE] to discharge on [DATE] revealed, the first documentation of any area of concern on CR #1's toe was made by LVN T on 01/29/25. Varied staff continued to document the area of concern as a scab or chronic scab. There was no notification or interventions noted.01/29/25 signed by LVN T- Skin warm dry and intact, scab to L great toe.02/02/25 signed by LVN T- Scab to left great toe. No new skin issues noted.02/11/25 signed by LVN T- Scab to left great toe. No new skin issues noted.02/18/25 signed by LVN S- no skin issues02/21/25 signed by Wound Care Nurse B- no new skin issue noted, right leg amputated, old scab to left great toe.02/25/25 signed by LVN T- old scab to left great toe. Right AKA with old scar. Skin warm, dry and intact.03/05/25 signed by Wound Care Nurse B- no new skin issue noted03/12/25 signed by LVN T- old scab/scar noted to left great toe.03/19/25 signed by LVN S- old scab to left great toe; skin intact.03/26/25 signed by LVN T- old scab to left great toe; skin warm, dry and intact.04/01/25 signed by LVN G- no new concerns.04/09/25 signed by LVN T- old scab to left great toe.04/15/25 signed by LVN Dno skin alterations.04/23/25 signed by LVN T- old scab L great toe.04/30/25 signed by LVN D- no skin alterations.05/06/25 signed by LVN T- chronic scab to left great toe.05/14/25 signed by LVN D- no skin alterations.05/20/25 signed by LVN T- chronic scab to left great toe.05/28/25 signed by LVN D- no skin alterations.06/01/25 signed by LVN B- no skin alterations.06/04/25 signed by LVN T- chronic scab/dry patch to left great toe.06/11/25 signed by LVN D- no new skin problems noted at this time, skin within limits.06/12/25 signed by LVN D- resident left big toe has bruising on the top of toe. Record review of CR #1's Assessments from 09/17/24 to 06/17/25 revealed, no documented CIC or SBAR regarding CR #1's left great toe.Record review of CR #1's Final X-ray Report dated 06/16/25 at 03:13 PM revealed, negative for acute disease, mild bone weakening and degenerative changes present.Record review of CR #1's Wound Management Detail Report revealed there were no previously documented wounds prior to 06/13/25:06/13/25 at 11:16 PM signed by Wound Care Nurse A: Wound Type: Diabetic Ulcer; Wound location left big toe; 0.8X0.5 cm, with no odor or drainage; depth of injury- through the dermis (skin) and down to the subcutaneous (under the skin) tissue, muscle.06/16/25 at 06:08 PM signed by Wound Care Nurse B: Wound Type: Trauma; Wound Location: Left big toe; to left great toe measuring 1.2x2x0.1cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection. Record review of CR #1's NP Progress Note dated 06/16/25. During the weekend nursing report of bruising and pain left first toe unclear how this happened. STAT x-ray ordered, wound care team following applied Bactroban. Physical Exam-Skin: Extremities- right AKA, left first toe swelling and tenderness; Musculoskeletal: :left first toe tenderness swelling and bruising, right AKA. Left first toe open wound minimal drainage/no bleeding. Diagnosis/Assessment and Plan left first toe swelling and report of some bleeding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 3 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some during the weekend, wound care team following, trauma wound left great toe unclear how this happened. Discussed with the wound doctor. xray shows no fracture. Open wound- left great toe trauma wound nailbed, wound care team following continue care treatments monitored closely. Left great toe pain likely due to trauma wound, ordered Acetaminophen 650 mg twice daily for 7 days and monitor.Record review of CR #1's Physician Order dated 06/17/25 revealed, daily wound treatment: diabetic ulcer left big toe. Cleanse with ns, pat dry with sterile gauze apply skin prep and leave open to air daily.Record review of CR #1's Assessments from 09/17/24 to 06/17/25 revealed, no documented CIC or SBARs regarding the area of concern identified by LVN T on the weekly skin assessment dated [DATE].Record review of CR #1 Hospital Records dated 06/17/25 revealed, CR #1 had a right foot diabetic foot ulcer in 07/2024 and then an above the knee amputation. She presented with left first toe ulceration and discharge and her final admitted diagnoses were toe infection and gangrene (death of body tissue due to lack of blood infection or a serious infection) of the toe. Record review of CR #1's Hospital Hospitalist Consult dated 06/18/25 revealed, CR #1 had a PMH of significant dementia, diabetes, hypertension, high cholesterol, severe PAD (vascular disease in which narrowing of the blood vessels result in the limbs not receiving oxygen), right heel wound with AKA who presents with left foot wound.Record review of CR #1 Hospital Podiatrist Consult dated 06/18/25 revealed, gangrene over 50% of the left foot, acute signs infection extending from the big toe to the middle of the top of his foot, with minimal pulses in the foot and pain when touching the big left toe.Record review of CR #1's Internal Medical Progress Note dated 06/18/25 revealed, left big toe with dry gangrene with variating tone skin changes extending to the ankle. Record review of CR #1's Hospital Vascular Surgery consult dated 06/19/25 revealed, left 1st toe with dry gangrene with no drainage, redness on the top of the foot and no withdrawing with pain when touched.Record review of CR #1's Hospital Vascular Ultrasound dated 06/20/25 revealed, significant blockage of blood flow to the lower leg and foot.Record review of CR #1's Hospital Podiatrist Consult dated 06/23/25 revealed, CR #1s left food infection had improved. Extensive conversation with multiple family members at bedside, although no urgent findings in the lower extremity, concerns for gas and osteomyelitis are stable within the digit and no systemic signs of infection. Given contralateral amputation, gangrene with vascular disease on clinical exam, patient in need of leg amputation. However, since family refuses amputation, conservative treatment options are unlikely to be successful without improved arterial flow to the foot.Record review of CR #1's Hospital Infectious Disease consult dated 06/24/25 revealed, without an amputation, conservative treatment options are unlikely to be successful especially in the setting of impaired arterial blood flow.Record review of CR #1's Hospital Palliative Care Consult dated 06/24/25 revealed, CR #1's family decided against leg amputation as was recommended as they do not believe that it would improve her quality of life and would likely cause her to suffer. The family discussed alternatives to pursuing leg amputation, and hospice was discussed as a way to provide CR #1 care to keep her comfortable.Record review of email communications between the Social Worker and Medical Records dated 07/09/25 revealed, CR #1 had no documented visits or services with podiatry.An observation of pictures of CR #1's left foot dated 06/13/25 at 03:14 PM revealed, resident's foot was dry and flaky. Toenails on her three lesser toes were long and curled around the tip of her toes; with an appearance that they had not been cut for months. Bruising was observed to the upper foot by the great toe and a thick deep callus with a dark/black hole in the center. Her great toenail was thickened and yellow but attached to the nail bed.An observation of pictures of CR #1's left foot dated 06/16/25 at 06:33 PM revealed, the skin on the tip of her left toe to be open. The wound to the tip was shiny and red, with dry blood on the nail bed under the nail. Her left great toenail appeared to be lifted off the nail (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 4 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some bed with visible dry black blood under.An observation on 06/22/25 at 05:00 PM revealed, CR #1 lying in a hospital bed. The resident had no leg on the right side and her left foot was surrounded with a dressing, the tip of her great toe was exposed and red irritated skin with a circular callused area visible. CR#1 was confused and non-interviewable; she reference people and things that were not in the room.In an interview on 07/08/25 at 02:41 PM, the Hospital Podiatrist said CR #1 had significant history of PVD that resulted in her having an AKA on her right leg in 08/2024, and her vascular disease was so significant it caused her severe dementia. He said a resident with history of diabetes, PVD and a previous AKA should have had routine podiatrist visit. The Hospital Podiatrist said in the hospital CR#1 was diagnosed with osteomyelitis (bacterial bone infection) that needed to be treated with IV antibiotics in order to save the limb. He said routine podiatry would have prevented the acute traumatic event (toe infection) but due to her extensive PVD, CR#1 would have eventually needed an amputation in the future. The Hospital Podiatrist said from what he saw CR #1's left great toenail was lifted from the nail bed but there was no active or raging infection visible, the resident's WBCs were normal, and she did not have a fever during her entire stay. He said since an AKA would not better the CR#1's quality of life and the residents significant dementia, CR #1's family decided to place her on palliative (end of life) care. In an interview on 07/09/25 at 10:43 AM, Wound Care Nurse B said when she saw CR #1 on 06/16/25 she had a left great toe arterial ulcer and dried blood on her nailbed. She said Wound Care Nurse A had previously contacted the doctor, so she did the treatment for the day and CR #1's big toe had no active bleeding, but it was purple. Wound Care Nurse B said after treatment she requested a podiatry consult for the resident and CR #1 never had any podiatrist services prior to her request on 06/16/25 and the Social Worker was responsible for ensuring residents received podiatry services. She said she did not know how CR #1 suffered from the injury to her nailbed, but LVN D would be the best person to talk about the initial injury. In an interview on 07/09/25 at 11:04 AM, the Social Worker said she facilitated podiatry services for facility residents. She said anyone with feet could receive podiatry services but often not skilled because of funding, since the services will come from their pool of money, unless the resident had issues with their feet. The Social Worker said some issues that trigger podiatry services were ingrown or thick and long toenails, and if a resident had these issues she would ask their family/RP if they would like podiatry services and if they said yes she would send a referral to the podiatrist. She said a resident with diagnoses of vascular disease, diabetes and a previous AKA should have been followed by Podiatry, she said she was notified by nursing staff on 06/16/25 and she put in a podiatrist referral but CR #1 went to the hospital the next day so she was never seen by a podiatrist. The Social Worker said only nurses were allowed to cut the nails of diabetics [SP5] but after looking at the picture of CR #1's toenails she said facility nurses would not touch that, that would be podiatry and based on the picture CR#1 should have received podiatry care. She said after reviewing CR #1's chart there was no evidence to show the resident received podiatry care from admission till discharge and she had no records of placing a podiatry referral. The Social Worker said she did not remember being notified by a floor nurse or wound care nurse that CR #1 required podiatry services, and she does not know about referrals unless notified by the facility staff or family. In an interview on 07/09/25 at 11:39 AM, Wound Care Nurse A said CR #1 had a diabetic foot ulcer/callused area on her left great toe and she found out about in on the day she assessed it (06/13/25). She said the first day she saw it, the area was dry and callused, and it had been there for a while but there was nothing for her to follow at the time. Wound Care Nurse A said a resident that had a chronic area like what she observed on CR #1 should have been referred to podiatry and she did not recall the ulcer/callus being on CR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 5 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #1's foot on admission so it was facility acquired. She said nurses do weekly skin assessments while the wound care nurse does the admission and readmission skin assessments, and they should always document what they saw. After reviewing the CR #1's chart Wound Care Nurse A said the first documentation of the left toe area of concern post admission was documented by 01/29/25 signed by LVN T and she should have notified the wound care team because diabetics wound injuries can be progress to a diabetic foot ulcer so they could watch it. She said diabetic foot management was important because diabetics can have prolonged wound healing, which could impact circulation, and a high-risk infection and podiatry should be involved because that was what they specialize in. Wound Care Nurse A said CR #1 should have been followed by podiatry based on her history and how her toes looked. She said based on the pictures of CR #1's toes between 06/13/25 and 06/16/25, the residents toenails appeared that she had not received nail care for a period she cannot say and based on the appearance of her toenails podiatry would have been responsible to cut CR #1's nails. Wound Care Nurse A said she did not know if CR #1 received podiatry services prior to her being alerted in June but she was placed on the list once she became aware. She said a podiatrist was required to cut resident's like CR #1's to prevent infections. Wound Care Nurse A said the facility podiatry protocol started when a floor nurse notified the wound care nurse of a foot concern, after the wound care nurse assess the resident, they notified the social worker who would then put in the referral and notified the physician who would then round on the resident. She said to her knowledge the facility protocol to request a podiatry referral was not followed because she was never notified of CR #1's foot concern. Wound Care Nurse A said podiatry care in residents like CR #1 was important to prevent the long nails that can become imbedded or snag leading to trauma. She said a resident with PVD who had unaddressed foot care could result in infection, gangrene and ultimately infection, Wound Care Nurse A said CR #1 had 2 issues with her big toe, when she first saw her it was suspected trauma to the big toe, there was discoloration to the top of the foot and blood on the edge of the nail but she had no idea how the trauma occurred. She said it looked like CR #1 snagged her left on something. Later on, CR #1 suffered from a diabetic foot ulcer on the tip of her great toe.In an interview on 07/09/25 at 12:20 PM, Wound Care Nurse B who was acting as the Interim DON at the time of the interview said the wound care team was never notified of any concerns to CR #1's feet prior to 06/13/25. She said when a resident had PVD and diabetes there was a concern that any wound could lead to a severe infection and with insufficient oxygen it can lead to necrosis (tissue death), so special focus should be placed on foot care. She said any toenail care provided to residents with extensive PVD, diabetes, or thick fungus nails should be provided by podiatry and CR #1's records showed had no documentation of any toenail care. Wound Care Nurse B said unkempt nails, can lead to scratches & wounds, and if the nail snagged on something it could result in trauma. Wound Care Nurse B said there were 2 different problems on CR #1's great toe, the 1st was a callus that had been there for a while that developed into an ulcer and then there was some kind of trauma but no one in the facility knows how it happened. She said the NP saw CR #1 and said the resident had suffered from trauma to her great toe. She said improper foot care in a resident with extensive PVD, diabetes and AKA could lead to worsening of a wound, improper circulation causing infection, necrosis, osteomyelitis and eventually amputation if not properly treated.In an interview on 07/09/25 at 12:35PM, the MD said CR #1 had extensive vascular disease and had an avulsed toenail (when toenail is partially or completely torn away from the nail bed). He said it looked like the toenail got hit on something and suffered some sort of trauma. The MD said the expectation for a resident like CR #1 who had vascular disease, diabetes and a previous AKA was for their foot or feet to get continuous evaluation by nursing to identify any issues. He said residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 6 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some with vascular disease and diabetes should be followed by podiatry because they can trim resident nails without damage to reduce the risk of infection. The MD said infection was a concern in residents with PVD because they do not have adequate blood floor to the feet to take care of the infection and if not properly/timely treated could result in damage to the digit (toe), cellulitis (skin infection), sepsis (blood infection) and gangrene. He said his expectation was that nursing staff should have notified the primary doctor and wound care nurse of any foot concerns so that the appropriate treatment would be started. The MD said prior to mid-June he was not aware CR #1 had any chronic foot ulcers/calluses and he did not know she had long toenails or needed podiatry services because she was never on any list for any foot concerns. In an interview on 07/10/25 at 02:32 PM, Wound Care Nurse B who was the interim DON at the time said neglect was the failure to provide care for the resident. She said prior to admission the MDS Nurse and DON reviews the resident's chart looking at diagnosis, present history, medication list, plan and therapy needed to ensure the facility was able to meet the resident needs. Wound Care Nurse B said failure to provide services was neglect, which could result in deterioration/worsening of health conditions, untreated health conditions, infections, and other conditions. She said based on CR #1's diagnosis of diabetes and previous AKA she should have had a podiatrist evaluation and been followed by the podiatrist. In an interview on 07/09/25 at 12:59 PM, ADON A said she was the ADON on CR #1's Hall. She said she was never aware of or notified of anything/concerns on CR #1's toes. She said in residents like CR #1 with diabetes, vascular disease, and a previous AKA nursing staff were concerned about feet especially any discoloration, openings or change in tissues because they can lead to ulcers and wounds which were made worse due to the resident having bad circulation. ADON A said infections in residents with PVD can lead to major wounds and ultimately amputation, so nail care was especially important to prevent scratches or other trauma. She said the Podiatrist was responsible for nail care in residents like CR #1 and their services were initiated when a CNA or family notify nursing administration of the residents need for podiatry services. ADON A said she was never notified that CR #1 needed podiatry services, and prior to June she was unaware CR #1 had a scabs, bruising, calluses, or areas of concerns on her toes. She said LVN T never alerted her of any concerns to her toes. ADON A said based on the record she reviewed and the presentation of CR #1 the area of concern documented for the 1st time on LVN T's documented skin assessment on 01/29/25 should have been a CIC and CNAs should have documented on the residents toes which included toenail length or the presence of any injuries/calluses etc. After looking at the pictures of CR #1's left great toe on 06/13/25 & 06/16/25, ADON A said she was never aware of anything like what the pictures showed until after CR #1 discharged from the facility. She said she investigated the trauma CR #1 suffered to her toenail between 06/13/25 and 06/16/25 and none of the nursing staff was aware of how the trauma occurred. ADON A said in the pictures presented it appeared CR #1 had not received nailcare for several months as the nails appeared to be double that of the nailbed with the 2-4th toenails curing around the tip of her toes. She said it was never on their radar that CR #1 had not received podiatry care while at the facility. In an interview on 07/09/25 at 01:22 PM, the NP said she was notified over the weekend (06/13 to 06/15/25) that CR #1 had bruising to her toe and foot, so she ordered and Xray of the foot which came back as negative for any acute findings. She said when she saw CR #1 on 06/16/25 the resident was experiencing pain and, there was an open area with a scab to her great toe. The NP said the wound care nurse already spoke to the wound care doctor and ordered a podiatry consult but no one knew what happened. She said there was bruising on the toes and foot, minor swelling, no drainage or other signs of infection and CR #1's left foot particularly the toe appeared to have suffered trauma. The NP said residents with diabetes, PVD and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 7 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete previous AKA were expected to have their feet monitored for infection and receive podiatry follow up monthly to prevent infection that could lead to osteomyelitis. She said CR #1 was one of her residents and she did not have any wounds or areas of concern prior to mid-June. The NP said the first time she saw CR #1's feet she had concerns it was a fracture, the resident had a dry wound, but the resident's family was very concerned because this was how CR #1's right side AKA started and wanted her to go to the hospital for treatment. She said she did not think that CR #1 needed to go to the hospital at the time because it looked like bruising from trauma not cellulitis. The NP said she did not know that CR #1 had not received podiatry services from admission but after she saw her, she was referred to podiatry. In an interview on 07/09/25 at 03:33 PM, CNA K said she sometimes provided care to CR #1, and she was not aware of any wounds at the tip of her toes. She said she never assisted with showers because the resident was on afternoon showers but when showering residents staff were expected to look for anything new from head to toe. CNA K said staff may not specifically look at the tip of the toe. In an interview on 07/09/25 at 04:23 PM, LVN D said during daily rounds on 06/12/25 it looked like CR #1 had stubbed her toe, it was light red, so she documented it and notified the wound care nurse. She said CR #1's toe appeared the same the next day but on the following day it looked like it was bleeding, so she texted the NP. LVN D said she worked with CR #1, and she thought the resident had a circular scab on the tip of her toe, but she cannot say if it was the chronic scab she documented on her weekly skin assessments, she said I always just saw it on her toe. LVN D said diabetics were expected to have weekly observations with emphasis on their feet, but she never notified anyone of the chronic scab on CR #1's foot because she thought the facility was already monitoring it, so it was not a change of condition and CR #1's nails were fine they were not long. LVN D said nurses performed toenail care and she could not think of the top of her head which residents required a podiatry referral but from what she could remember CR #1's toenails were normal and did not require a podiatrist. She said long toenails in a diabetic resident with vascular complications could lead to the nail splitting, getting snagged, damage, infection and if untreated it can quickly turn into a complicated situation leading to amputation.In an interview on 07/11/25 at 09:19 AM, the Former DON, said she served as the [NAME] from 04/07/25 to 06/27/25 so she was not the DON when CR #1 admitted to the facility. She said she only has general knowledge about CR #1 because as the DON she Event ID: Facility ID: 676450 If continuation sheet Page 8 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 residents (CR #1) reviewed for accuracy of assessments. - The facility failed to identify CR # 1's diagnosis of vascular diseases (narrowing of the blood vessels that result in oxygen not getting sent to the limbs also called PVD) and document it in her MDS(s) which resulted in CR #1 not having a plan of care for her diagnosis. These failures could place residents at risk of a compromised plan of care, worsening of health conditions, infection, injury, and amputation. Findings include: Record review of CR #1's Face Sheet dated 06/22/25 revealed, a 69-year-olf female who admitted to the facility on [DATE] at 12:45 PM with diagnosis which included: Alzheimer's Disease, unspecified dementia with anxiety, hypertension (high blood pressure), acquired absence of right leg above knee (right above the knee amputation) and type 2 diabetes with other circulatory complications. Diagnosis of open wound of left great toe without damage to nail was added on 06/15/25; and unspecified wound, left foot initial encounter was added on 06/16/25. There was no documented diagnosis of PVD. Record review of CR #1's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, resident was unable to complete a brief interview of mental status, lower extremity functional limitation in range of motion. Active diagnoses of anemia, hypertension, diabetes, hyperlipidemia(high cholesterol), Alzheimer's Disease, seizure disorder, depression; there were no diagnosis of PVD or any circulatory complications. Record review of CR #1's undated Care Plan revealed , Focus- risk of falls due to immobility, muscle weakness and diabetes; Problem- CR #1 will be free from injury; approach- encourage resident to use environmental devices such as hand grips, handrails etc. Problem start date of 06/13/25- CR #1 has a diabetic ulcer to the left great toe; Goal target date 09/13/25- resident's wound will decrease in size with no complications as evidenced by wound documentation; Approach start date 06/13/25- nurse to complete wound documentation daily, refer to wound care doctor as needed, wound team to evaluate wound(s), treatments and healing status weekly. Problem start date of 06/16/25- CR#1 has trauma to left great toe; Goal target date: 09/16/25- wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained; Approach start date: 06/16/25- CNA to inspect skin, especially over bony prominences, during bathing and personal care. Nurse to complete wound observation weekly. there was no mention of podiatry care or services or her vascular disease. Record review of email communications between the Social Worker and Medical Records dated 07/09/25 revealed, CR #1 had no documented visits or services with podiatry. An observation of pictures of CR #1's left foot dated 06/13/25 at 03:14 PM revealed, resident's foot was dry and flaky. Toenails on her three lesser toes where long and curled around the tip of her toes; with an appearance that they had not been cut for months. Bruising was observed to the upper foot by the great toe and a thick deep callus with a dark/black hole in the center. Her great toenail was thickened and yellow but attached to the nail bed.An observation of pictures of CR #1's left foot dated 06/16/25 at 06:33 PM revealed, the skin on the tip of her left toe to be open. The wound to the tip was shiny and red, with dry blood on the nail bed under the nail. He left great toenail appeared to be lifted off the nail bed with visible dry black blood under.An observation on 06/22/25 at 05:00 PM revealed, CR #1 lying in a hospital bed. The resident had no leg on the right side and her left foot was surrounded with a dressing, the tip of her great toe was exposed and red irritated skin with a circular callused area visible. CR#1 was confused and non-interviewable; she reference people and things that were not in the room.In an interview on 07/08/24 at 02:41 PM, the Hospital Podiatrist said CR #1 had significant history of PVD that resulted in her having an AKA on her right leg in 08/2024, and Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 9 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her vascular disease was so significant it caused her severe dementia. He said a resident with history of diabetes, PVD and a previous AKA should have had routine podiatrist visit. The Hospital Podiatrist said in the hospital CR#1 was diagnosed with osteomyelitis (bacterial bone infection) that needed to be treated with IV antibiotics in order to save the limb. He said routine podiatry would have prevented the acute traumatic event (toe infection) but due to her extensive PVD, CR#1 would have eventually needed an amputation in the future. The Hospital Podiatrist said from what he saw CR #1's left great toenail was lifted from the nail bed but there was no active or raging infection visible, the resident's WBCs were normal, and she did not have a fever during her entire stay. He said since an AKA would not better the CR#1's quality of life and the residents significant dementia, CR #1's family decided to place her on palliative (end of life) care.In an interview on 07/14/25 at 01:36 PM, the MDS coordinator said she was responsible for completing MDS assessments for long term care residents including CR #1. She said the MDS paints the entire picture of the resident including the level of care needed, level of ADLs, everything the facility was doing for the resident and it was a 7-day look back. The MDS nurse said the MDS functions to make sure appropriate level of care was given to a resident and it triggers CAAS which were care areas that were used to develop the residents plan of care. She said when a resident admits, the MDS nurse enters the residents admitting diagnosis which can be retrieved from the hospital documents or provided by the facility doctor. The MDS Nurse said if there was an MDS discrepancy it would not trigger a care area that the resident might need services for, and the area may not make it to the resident's plan of care. She said failure to not having a plan of care for a resident's diagnosis could place them at risk of not getting appropriate care, resulting in an untreated disease, or worsening health condition. After reviewing CR #1's records, the facility's diagnosis of diabetes with vascular complications should have been documented as PVD in the resident's MDS. She said PVD was when a resident did not get sufficient blood flow which brings oxygen to their peripheral (limbs) which leads to loss of feeling, loss of blood and ultimately a loss of a limb. The MDS nurse said when the resident admitted to the facility, nursing staff should have gotten clarification for what CR #1's circulatory complication was in order for her to receive adequate care she needed. She said after reviewing CR #1's chart, the resident did not have a plan of care for her circulatory condition, and the typical plan of care for PVD included podiatry services. The MDS nurse said the resident's circulatory complications did not make it into the residents plan of care because the CAAs were not triggered by the MDS.In an interview on 07/21/25 at 01:45 PM, Wound Care Nurse B said the facility failed to get clarification on what the diagnosis of the resident's circulatory complication was which then impacted her MDS, the plan of Care and ultimately resulted in the failure to provide podiatrist services.In an interview on 07/21/25 at 03:05 PM, the MDS Nurse said the facility's failure to provide CR #1' podiatry services started from the failure to get the correct diagnosis of PVD from the doctor and that trickled down.Record review of the facility policy Minimum Data Set (MDS) revised 05/05/23 revealed, POLICY: A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. The comprehensive assessment is completed initially and periodically. Quarterly and Significant Change assessments are completed as required, following the RAI specific guidelines. State-specific versions of such assessments are completed within the required timeframes according to applicable law and regulations. The Facility uses the RAI specified by CMS (which includes the MDS, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 10 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete utilization guidelines and the CAAs) to assess each resident and develop a comprehensive care plan. The facility is responsible for addressing all the needs and strengths of each resident. Each staff member will note their liability for the accuracy of the data recorded by signing (electronically) their name and identifying the MDS sections and questions to which they provided responses. A registered nurse (RN) must sign and certify that the assessment is completed. PROCEDURES: 1. Review the resident's medical record. This review may include pre-admission activities. Identify resident's status, care and services rendered during the Observation Period for the current assessment. Review is to include, but not be limited to pre-admission, admission, and transfer notes; current plan of care, physicians' orders, progress notes, history and physical; nursing, dietary, activity, social service, and therapy notes and assessments; monthly summaries, lab and x- ray reports, consultations, medication administration records, treatment administration records, and resident, staff and family interviews. 2. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Supplemental information must be gathered and analyzed by the facility based on the triggered CAAs prior to developing the comprehensive care plan. Documentation of the facility's rationale for deciding whether or not to proceed with care planning for each area triggered is recorded in the medical record. The Facility addresses all risks identified within the context of the MDS assessment, even if they do not cause a CAA to trigger. 9. Each assessment must represent an accurate picture of the resident's status during the observation period of the MDS. Event ID: Facility ID: 676450 If continuation sheet Page 11 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 - Immediate jeopardy to resident health or safety 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 observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 Residents (CR #1 ) reviewed for care plans. The facility failed to develop and implement a plan of care for CR #1's PAD ( a specific form of PVD in which there is narrowing of blood vessels taking blood to the extremities, leading to low or no oxygen), which resulted in CR #1 not receiving podiatry care from admission on [DATE] till she discharged to the hospital on [DATE] (9 months) where she was diagnosed with a osteomyelitis (bacterial bone infection), with a recommendation for a left side AKA and ultimately placed on hospice services. An Immediate Jeopardy (IJ) was identified on 07/09/2025. The IJ template was provided to the Administrator on 07/09/2025 at 04:57 PM. While the immediacy was removed on 07/14/2025 at 3:18 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not having their needs met, injuries, infections, unwanted hospitalization, amputation leading to a decrease in quality of life and death. Findings include: Record review of CR #1's Face Sheet dated 06/22/25 revealed, a 69-year-olf female who admitted to the facility on [DATE] at 12:45 PM with diagnosis which included: Alzheimer's Disease, unspecified dementia with anxiety, hypertension (high blood pressure), acquired absence of right leg above knee (right above the knee amputation) and type 2 diabetes with other circulatory complications. Diagnosis of open wood of left great toe without damage to nail was added on 06/15/25; and unspecified wound, left foot initial encounter was added on 06/16/25. There was no documented diagnosis of PVD. Record review of CR #1's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, resident was unable to complete a brief interview of mental status, lower extremity functional limitation in range of motion. CR #1 needed substantial/maximal assistance to : roll left and right, move from sitting to lying and lying to sitting on side of bed, was totally depended on to transfer from chair to bed and vice versa, evaluation of her ability to walk 10 ft, toilet transfer, tub/shower transfer or go from sit to stand was not attempted due to her medical condition or safety concerns. Active diagnoses of anemia, hypertension, diabetes, hyperlipidemia(high cholesterol), Alzheimer's Disease, seizure disorder, depression; there were no diagnosis of PVD or any circulatory complications. Record review of CR #1's undated Care Plan revealed, Focus- risk of falls due to immobility, muscle weakness and diabetes; Problem- CR #1 will be free from injury; approach- encourage resident to use environmental devices such as hand grips, handrails etc. Problem start date of 06/13/25- CR #1 has a diabetic ulcer to the left great toe; Goal target date 09/13/25resident's wound will decrease in size with no complications as evidenced by wound documentation; Approach start date 06/13/25- nurse to complete wound documentation daily, refer to wound care doctor as needed, wound team to evaluate wound(s), treatments and healing status weekly. Problem start date of 06/16/25- CR#1 has trauma to left great toe; Goal target date: 09/16/25- wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained; Approach start date: 06/16/25- CNA to inspect skin, especially over bony prominences, during bathing and personal care. Nurse to complete wound observation weekly. There was no mention of podiatry care or services, her circulatory complications or vascular disease.Record review of CR #1's Progress Notes from admission on [DATE] to discharge on [DATE] revealed, There was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 12 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 - Immediate jeopardy to resident health or safety Residents Affected - Some documentation that CR #1 received podiatry care while at the facility with the following relevant entries.Record review of CR #1's Point of Care History from 09/17/24 to 06/17/25 revealed, no documentation of toenail care to CR #1.Record review of CR #1's Wound Management Detail Report dated 06/22/25 revealed there were no previously documented wounds prior to 06/13/25:06/13/25 at 11:16 PM signed by Wound Care Nurse A: Wound Type: Diabetic Ulcer; Wound location left big toe; 0.8X0.5 cm, with no odor or drainage; depth of injury- through the dermis (skin) and down to the subcutaneous (under the skin) tissue, muscle.06/16/25 at 06:08 PM signed by Wound Care Nurse B: Wound Type: Trauma; Wound Location: Left big toe; to left great toe measuring 1.2x2x0.1cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection. Record review of CR #1 Hospital Records dated 06/17/25 revealed, CR #1 had a right foot diabetic foot ulcer in 07/2024 and then an above the knee amputation. She presented with left first toe ulceration and discharge and her final admitted diagnoses were toe infection and gangrene (death of body tissue due to lack of blood infection or a serious infection) of the toe. Record review of CR #1's Hospital Hospitalist Consult dated 06/18/25 revealed, CR #1 had a PMH of significant dementia, diabetes, hypertension, high cholesterol, severe PAD (vascular disease in which narrowing of the blood vessels result in the limbs not receiving oxygen), right heel wound with AKA who presents with left foot wound.Record review of CR #1 Hospital Podiatrist Consult dated 06/18/25 revealed, gangrene over 50% of the left foot, acute signs infection extending from the big toe to the middle of the top of his foot, with minimal pulses in the foot and pain when touching the big left toe.Record review of CR #1's Internal Medical Progress Note dated 06/18/25 revealed, left big toe with dry gangrene with variating tone skin changes extending to the ankle. Record review of CR #1's Hospital Vascular Surgery consult dated 06/19/25 revealed, left 1st toe with dry gangrene with no drainage, redness on the top of the foot and no withdrawing with pain when touched.Record review of CR #1's Hospital Vascular Ultrasound dated 06/20/25 revealed, significant blockage of blood flow to the lower leg and foot.Record review of CR #1's Hospital Podiatrist Consult dated 06/23/25 revealed, CR #1s left food infection had improved. Extensive conversation with multiple family members at bedside, although no urgent findings in the lower extremity, concerns for gas and osteomyelitis are stable within the digit and no systemic signs of infection. Given contralateral amputation, gangrene with vascular disease on clinical exam, patient in need of leg amputation. However, since family refuses amputation, conservative treatment options are unlikely to be successful without improved arterial flow to the foot.Record review of CR #1's Hospital Infectious Disease consult dated 06/24/25 revealed, without an amputation, conservative treatment options are unlikely to be successful especially in the setting of impaired arterial blood flow.Record review of CR #1's Hospital Palliative Care Consult dated 06/24/25 revealed, CR #1's family decided against leg amputation as was recommended as they do not believe that it would improve her quality of life and would likely cause her to suffer. The family discussed alternatives to pursuing leg amputation, and hospice was discussed as a way to provide CR #1 care to keep her comfortable.Record review of email communications between the Social Worker and Medical Records dated 07/09/25 revealed, CR #1 had no documented visits or services with podiatry.An observation of pictures of CR #1's left foot dated 06/13/25 at 03:14 PM revealed, resident's foot was dry and flaky. Toenails on her three lesser toes where long and curled around the tip of her toes; with an appearance that they had not been cut for months. Bruising was observed to the upper foot by the great toe and a thick deep callus with a dark/black hole in the center. Her great toenail was thickened and yellow but attached to the nail bed.An observation of pictures of CR #1's left foot dated 06/16/25 at 06:33 PM revealed, the skin on the tip of her left toe to be open. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 13 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 - Immediate jeopardy to resident health or safety Residents Affected - Some The wound to the tip was shiny and red, with dry blood on the nail bed under the nail. He left great toenail appeared to be lifted off the nail bed with visible dry black blood under.An observation on 06/22/25 at 05:00 PM revealed, CR #1 lying in a hospital bed. The resident had no leg on the right side and her left foot was surrounded with a dressing, the tip of her great toe was exposed and red irritated skin with a circular callused area visible. CR#1 was confused and non-interviewable; she reference people and things that were not in the room.In an interview on 07/08/24 at 02:41 PM, the Hospital Podiatrist said CR #1 had significant history of PVD that resulted in her having an AKA on her right leg in 08/2024, and her vascular disease was so significant it caused her severe dementia. He said a resident with history of diabetes, PVD and a previous AKA should have had routine podiatrist visit. The Hospital Podiatrist said in the hospital CR#1 was diagnosed with osteomyelitis (bacterial bone infection) that needed to be treated with IV antibiotics in order to save the limb. He said routine podiatry would have prevented the acute traumatic event (toe infection) but due to her extensive PVD, CR#1 would have eventually needed an amputation in the future. The Hospital Podiatrist said from what he saw CR #1's left great toenail was lifted from the nail bed but there was no active or raging infection visible, the resident's WBCs were normal, and she did not have a fever during her entire stay. He said since an AKA would not better the CR#1's quality of life and the residents significant dementia, CR #1's family decided to place her on palliative (end of life) care.In an interview on 07/09/25 at 11:04 AM, the Social Worker said a resident with diagnoses of vascular disease, diabetes and a previous AKA should have been followed by Podiatry, The Social Worker said only nurses were allowed to cut the nails of diabetes but after looking at the picture of CR #1's toenails she said facility nurses would not touch that, that would be podiatry and based on the picture CR#1 should have received podiatry care. She said after reviewing CR #1's chart there was no evidence to show the resident received podiatry care from admission till discharge and she had no records of placing a podiatry referral. The Social Worker said she did not remember being notified by a floor nurse or wound care nurse that CR #1 required podiatry services, and she does not know about referrals unless notified by the facility staff or family.In an interview on 07/09/25 at 12:35PM, the MD said prior to mid-June he was not aware CR #1 had any chronic foot ulcers/calluses and he did not know she long toenails or needed podiatry services because she was never on any list of any foot concerns.In an interview on 07/14/25 at 01:36 PM, the MDS coordinator said she was responsible for completing MDS assessments and care plans for long term care residents including CR #1, She said the MDS paints the entire picture of the resident including the level of care needed, level of ADLs, everything the facility is doing for the resident and it is a 7-day look back. The MDS nurse said the MDS functions to make sure appropriate level of care is given to a resident and it triggers CAAS which are care areas that are used to develop the residents plan of care. She said when a resident admits the MDS nurse enters the residents admitting diagnosis which can be retrieved from the hospital documents or provided by the facility doctor. The MDS Nurse said if there was an MDS discrepancy it would not trigger a care area that the resident might need services for, and the area may not make it to the resident's plan of care. She said the care plan painted a picture of the resident and functioned as their plan of care and addressed their diagnosis, medications, diet, wounds, etc. She said failure to not having a plan of care for a resident's diagnosis could place them at risk of not getting appropriate care, resulting in an untreated disease, or worsening health condition. After reviewing CR #1's records, the facility's diagnosis of diabetes with vascular complications should have been documented as PVD in the resident's MDS. She said PVD is when a resident did not get sufficient blood flow which brings oxygen to their peripheral (limbs) which leads to loss of feeling, loss of blood and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 14 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 - Immediate jeopardy to resident health or safety Residents Affected - Some ultimately a loss of a limb. The MDS nurse said when the resident admitted to the facility, nursing staff should have gotten clarification for what CR #1's circulatory complication was in order for her to receive adequate care she needed. She said after reviewing CR #1's chart, the resident did not have a plan of care for her circulatory condition, and the typical plan of care for PVD included podiatry services. The MDS nurse said the resident's circulatory complications did not make it into the residents plan of care because the CAAs were not triggered by the MDS.In an interview on 07/21/25 at 01:45 PM, Wound Care Nurse B said the facility failed to get clarification on what the diagnosis of the resident's circulatory complication was which then impacted her MDS, the plan of Care and ultimately resulted in the failure to provide podiatrist services.In an interview on 07/21/25 at 03:05 PM, the MDS Nurse said the facility's failure to provide CR #1' podiatry services started from the failure to get the correct diagnosis of PVD from the doctor and that trickled down.Record review of the facility policy Person-Centered Care Plan revised 10/1/2020 revealed, 3. The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care, and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible. The plan is also used to promote patient/resident and family involvement in planning care.Record review of the facility policy Care Plan Process, Person-Centered Care revised 05/05/25 revealed, The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. PROCEDURES: 1. Following RAI Guidelines develop and implement a comprehensive person- centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Record review of the facility policy Foot Care revised 05/05/23 revealed, Policy: the facility ensures foot care is provided in a manner that is consistent with professional standards of practice. Foot care includes treatment to prevent complications form conditions such as diabetes, peripheral vascular disease, or immobility. Procedures: 1- Upon admission a resident will be assessed for any diagnosis or condition that poses a risk to foot health (diabetes, peripheral vascular disease, ingrown toenails, hammer toes, etc.). 2- Residents with a diagnosis or condition that places them at risk will be scheduled for routine foot care by the podiatrist. 3- Social services will validate the residents payer source coverage for podiatric visits and will discuss any payment issues with resident/legal representative prior to podiatric visit. 4- Social services will assist the resident in transportation to the podiatrist's office if the podiatrist does not see residents within the facility. 5- Nail trimming will be completed by the nursing assistant as necessary unless the following conditions are present; which require the skill of a licensed staff member. A- a resident has an at-risk diagnosis and has refused podiatric care. 6- The resident's care plan will reflect the need for podiatric services and any services that are provided by licensed nursing staff. An IJ was Identified on 07/09/2025. The Administrator was notified of the IJ, and the template was provided to the facility on [DATE] at 04:57 PM. The following Plan of Removal submitted by the facility was accepted on 07/11/2025 at 12:10 PM.PORThe facility failed to provide diabetic foot care which included podiatry services to CR#1. The facility failed to take action when an area of concern was first documented on 1/29/25 and 6/13/25 when it was the area became red, swollen with drainage.Resident #1 was discharged to the hospital on 6/17/25Residents in house will be assessed for any diagnosis or condition that poses a risk to foot health by the Director of Nursing/Designee by 7/10/25. 60 residents were identified with diagnosis or conditions that pose a threat to foot health. Eleven Residents not currently followed by podiatry were referred to podiatry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 15 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 - Immediate jeopardy to resident health or safety Residents Affected - Some services on 7/10/25Skin assessments will be conducted on residents inhouse on 7/10/25 by Nursing Leadership to identify skin integrity concerns on the feet. Findings will be communicated to the Director of Nursing/Designee. The Director of Nursing/designee will validate change of condition completed, provider and responsible party notified and interventions implemented on 7/10/25.Residents identified will be referred to podiatry by 7/10/25 by the Social Services Director.Podiatry services plan to visit facility to begin visits 7/14/25. Eleven residents were identified as needing a podiatry visit, a virtual visit was conducted on 7/10/25 with the medical director. No urgent needs were identified by the medical director during the visit and no new orders were given.Director of Nursing/designee will review by skin assessments from the last 7 days on 7/10/25 to validate provider notified, responsible party notified and interventions implemented. No new issues were identified.Residents identified will have provider notified for further direction and responsible party notified by 7/10/25 by the Director of Nursing/DesigneeResidents identified will have care plan's updated to validate appropriate interventions by the Director of Nursing/Designee by 7/10/25.Director of Nursing, Assistant Director of Nursing, and Social Services Director were reeducated by the Clinical Consultant by 7/10/25 on admission skin assessment including: identifying any diagnosis or condition that poses a risk to foot health (e.g., peripheral vascular disease, ingrown toenails, diabetes, hammer toes, etc.) when diagnosis or conditions posing a risk to foot health are identified, physician will be notified for treatment orders and social services will be notified for podiatry referral updating the care plan to reflect the current/new approaches during clinical morning meeting, concerns identified on a stop and watch form will be validating that concerns were addressed with physician and orders obtained and implemented.Licensed nurses will be re-educated by the Director of Nursing/Designee by 7/10/25 on the admission skin assessment including: identifying any diagnosis or condition that poses a risk to foot health (e.g., peripheral vascular disease, ingrown toenails, diabetes, hammer toes, etc.) when diagnosis or conditions posing a risk to foot health are identified, physician will be notified for treatment orders and social services will be notified for podiatry referral updating the care plan to reflect the current/new approaches Certified Nursing Assistants will complete skin checks during care to identify any skin integrity concerns. Any skin integrity concern is reported to the charge nurse upon discovery through use of stop and watch form. The licensed nurse will act upon the information communicated by evaluating the area of concern and notifying the physician for a treatmentLicensed Nurses will be re-educated by the Director of Nursing/Designee by 7/10/25 on change of condition including: Identifying, assessing and reporting acute change in condition, including abnormal vital signs, pain, changes in skin integrity and notifying the provider for further directionCertified Nursing Assistants will be reeducated by the Director of Nursing/Designee by 7/10/25 on: identifying and reporting changes in residents skin integrity to the licensed nurse upon discovery, skin integrity concerns identified will documented on a stop and watch form by the certified nursing assistant are given to the licensed nurse. The carbon copy will be placed in the Director of Nursing/Designee's box for reviewThis reeducation will be completed by 7/10/25. Target staff who have not received the re-education by this date will receive prior to their next scheduled shift and will be presented in New Hire and Agency Orientation.The Director of Nursing /Designee will review admission and weekly skin assessments Monday - Friday in clinical morning meeting beginning 7/11/25 to validate at risk residents with a diagnosis or condition that poses a risk to foot health (e.g., peripheral vascular disease, ingrown toenails, diabetes, hammer toes, etc.) have been identified with notifications to physician for treatment orders and social services for podiatry referral.The Director of Nursing/Designee will review residents identified at risk or with diagnosis or conditions that pose a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 16 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 - Immediate jeopardy to resident health or safety Residents Affected - Some risk to foot health in clinical morning meeting Monday - Friday to validate appropriate assessments are completed, care plans are updated with appropriate interventions, provider notified for treatment orders and responsible party notificationsDirector of Nursing or Designee will review the Facility Activity report and 24-hour report to identify any documentation regarding a change of condition and validate that the resident hasbeen assessed appropriately and provider notified. This will be completed Monday through Friday in the Clinical Morning meeting and by the weekend supervisor on the weekendsThe Director of Nursing/Designee will validate in clinical morning meeting any skin integrity concerns identified on a stop and watch form are addressed with physician and orders obtained and implemented.The Director of Nursing/Designee will validate following a podiatrist visit to the facility that residents with a podiatry referral were assessed by the podiatrist during their visit.Ad Hoc QAPI will be held on 7/9/25.The Medical Director was notified of the Immediate Jeopardy on 7/9/25 and updated of contents of this plan. Monitoring of the POR In an interview on 07/13/25 at 10:05 AM, day shift staff MA J said the facility abuse coordinator was the Administrator and she received an inservice on ANE, change of conditions, skin assessments, and care plans in the last 2 days. She said neglect was failure to provide services and she had not observed any in the building. MA J said when a CNA is providing showers, they were expected to observe the resident from head to tip of their toes and notify the nurse if there was anything out of the norm, document it on the shower sheet, the POC and complete a stop and watch form located at the nursing station. In an interview on 07/13/25 at 10:09 AM, day shift staff RN I said the facility administrator was the abuse coordinator, and she received training on ANE, change in condition, foot care, and care plans within the last week. She said neglect was failure to provide services and she had not observed any in the building. She said residents were to receive weekly skin assessments that assess the resident from head to toe for anything outside of normal limits. She said if something was identified the nurse must document it as a CIC, SBAR notify the MD and wound care team. She said diagnosis of diabetes, neuropathy and vascular disease placed residents at risk of foot issues, so residents with qualifying diagnosis should receive podiatry care and if they did not have an order staff should call the doctor to receive one. She said when a resident has a CIC nursing staff should make sure to update the residents care plan ensuring there were appropriate interventions in place. RN I said if a resident had a missing diagnosis nursing staff can add it to the residents chart after verification from the resident's MD. In an interview on 07/13/25 at 10:23 AM, day shift staff LVN E said the facility administrator was the abuse coordinator, and she received an in-service on ANE, CIC, foot care and care plans yesterday. She said neglect was failure to provide care and she had not observed any in the facility. LVN E said when performing a resident weekly skin assessments nursing staff must inspect the resident from head to toe, documenting everything they see on the chart, complete a CIC/SBAR for anything outside of the normal, and notify the MD and wound care team. She said residents with diabetes, PVD and neuropathy have increased risk for foot problems so they must observe them closely and ensure they have podiatry services in place. LVN E said nursing staff must notify the RN of any missing diagnosis or issues that need to get updated in the care plan. In an interview on 07/13/25 at 10:29 AM, day shift staff LVN O said the facility administrator was the abuse coordinator, and she received an in-service on ANE, CIC, foot care and care plans this morning. She said neglect was failure to provide care and she had not observed any in the facility. LVN O said when performing weekly skin assessments staff must document all changes in the residents chart, complete a CIC/SBAR and notify the care team. She said any changes in a resident should then be updated in their care plan and any missed diagnosis or care areas should be brought to the attention of the ADON and DON. In an interview on 07/13/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 17 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 - Immediate jeopardy to resident health or safety Residents Affected - Some 10:35 AM, day shift staff RN C said the facility administrator was the abuse coordinator, and he received training on ANE, change in condition, foot care, and care plans earlier this week. He said neglect was failure to provide services and he had not observed any in the building. RN C said when a resident experienced a new skin condition, they must document it in the residents chart as a CIC/SBAR and notify the wound care team who then notifies podiatry. He said diabetics and those with PVD and neuropathy were at an increased risk of complications with their feet, so podiatry was important . RN C said if a resident was missing a diagnosis or focus area on their care plan, the must notify the care coordinator to make updates. In an interview on 07/13/25 at 10:48 AM, day shift staff CNA AD said the facility administrator was the abuse coordinator, and she received training on ANE, change in condition, foot care, and care plans in the last 3 days. She said neglect was not meeting the residents' need and she had not observed any in the building. CNA AD said when staff observe changes in skin during showers, they must document it in the residents chart and notify nursing administration. In an interview on 07/13/25 at 10:55 AM, day shift staff RN J said the facility administrator was the abuse coordinator, and she received training on ANE, change in condition, foot care, and care plans this morning. She said neglect was failure to provide services and she had not observed any in the building. She said new admits with diabetes should have orders for podiatry evaluation and any changes in a residents skin seen during skin assessments must be documented as a CIC/SBAR and notifications sent to the MD, and nursing administration. RN J said if a resident had a change of condition or if staff notice a missing diagnosis or care area, they must notify MD for clarification. In an interview on 07/14/25 at 06:56 AM, night shift staff CNA D said she last received an in-service on ANE, change in condition, foot care, and care plans within the last 3 days and the facility abuse coordinator was the administrator. She said abuse was the failure to provide care and she had not observed any in the building. CNA D said when providing showers staff must observe the resident from head to toe, and any abnormalities should be documented in the shower sheet, POC, reported to the nurse and a stop and watch completed. In an interview on 07/14/25 at 06:56 AM, night shift staff LVN X said she last received an in-service on ANE, change in condition, foot care, and care plans yesterday and the facility abuse coordinator was the administrator. She said the facility had insufficient staff and she had witnessed a delay in care and medication but had no safety concerns about the staffing level. LVN X said when performing skin assessments, residents must be observed from head to toe and for diabetics there should be extra focus on pressure ulcers and foot care. She said if staff observed any variations from the norm, they must complete a CIC/SBAR, notify the MD, ask for necessary consultations and notify the PCP. LVN X said residents with vascular disease, diabetes and neuropathy were at risk of issues with foot health and they can lose their foot due to the lack of blood supply to the area. She said if a resident was missing a diagnosis or care area staff must contact the physician for clarification to ensure the diagnosis and care plan is updated. In an interview on 07/14/25 at 06:56 AM, night shift staff CNA M said she last received an in-service on ANE, change in condition, foot care, and care plans within the last 2 days and the facility abuse coordinator was the administrator. She said she had not observed any neglect in the building and staff must observe residents from head to toe during showers. Any changes observed in skin must be documented in the POC, shower sheet and in a stop and watch. CNA M said if a resident had long, and thick nails CNAs must notify nurse and request podiatry services. In an interview on 07/14/25 at 07:14 PM, night shift staff RN J said the facility administrator was the abuse coordinator, and she received training on ANE, change in condition, foot care, and care plans in the last 1-2 days. She said neglect was failure to provide care and she had not observed any in the building. RN J said foot care was important in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 18 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete diabetes because it was important to catch things early to prevent infection. She said any changes in a residents skin seen during skin assessments must be documented as a CIC/SBAR and notifications sent to the MD, and nursing administration to get podiatry services for the resident. RN J said if a resident had a change of condition or if staff notice a missing diagnosis or care area, they must notify MDS nurse to ensure the resident record is updated. In an interview on 07/14/25 at 07:22 AM, night shift staff CNA S said she last received an in-service on ANE, change in condition, foot care, and care plans was yesterday and the facility abuse coordinator was the administrator. She said she had not observed any neglect in the building and staff must observe residents from head to toe during showers. Any changes observed in skin must be documented in the POC, shower sheet and in a stop and watch. She said failure to identify and notify skin changes could place the resident at risk of worsening and escalation of the condition. In an interview on 07/14/25 at 07:22 AM, night shift staff CNA I said she last received an in-service on ANE, change in condition, foot care, and care plans 2 days ago and the facility abuse coordinator was the administrator. She said she had not observed any neglect in the building and staff must observe residents from head to toe during showers. Any changes observed in skin must be documented in the POC, shower sheet and in a stop and watch. She said failure to identify and notify skin changes would leave the issue untreated which could lead to infection. In an interview on 07/14/25 at 07:32 AM, night shift staff LVN Y said he last received an in-service on ANE, change in condition, foot care, and care plans yesterday and the facility abuse coordinator was the administrator. He said venous disorder, diabetes, and hammer toes placed residents at an increased risk for foot problems. LVN Y said when performing skin assessments, residents must be observed from head to toe and for diabetics there should be extra focus on pressure ulcers and foot car Event ID: Facility ID: 676450 If continuation sheet Page 19 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0687 Provide appropriate foot care. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health, and provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assist the resident in making appointments with a qualified person for 1 of 5 residents (CR #1) reviewed for foot care - The facility failed to provide foot care or attain podiatry services for CR #1, a diabetic patient with severe PAD (a form of PVD in which narrowing of the blood vessels limit blood flow to the limbs) and a history of AKA from admission on [DATE] till she discharged on 06/17/25 to the hospital where she was diagnosed with osteomyelitis (a bone infection) that needed antibiotics, an AKA was recommended resulting in the family placing the resident on end of life care. An Immediate Jeopardy (IJ) was identified on 07/09/2025. The IJ template was provided to the Administrator on 07/09/2025 at 04:57 PM. While the immediacy was removed on 07/14/2025 at 3:18 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for injuries, infections, unwanted hospitalization, an amputation leading to a decrease in quality of life and death. Findings Included: Record review of CR #1's Face Sheet dated 06/22/25 revealed, a 69-year-olf female who admitted to the facility on [DATE] at 12:45 PM with diagnoses which included: Alzheimer's Disease, unspecified dementia with anxiety, hypertension (high blood pressure), acquired absence of right leg above knee (right above the knee amputation) and type 2 diabetes with other circulatory complications. Diagnosis of open wound of left great toe without damage to nail was added on 06/15/25; and unspecified wound, left foot initial encounter was added on 06/16/25. There was no documented diagnosis of PVD. Record review of CR #1's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, resident was unable to complete a brief interview of mental status, lower extremity functional limitation in range of motion. CR #1 needed substantial/maximal assistance to : roll left and right, move from sitting to lying and lying to sitting on side of bed, was totally depended on to transfer from chair to bed and vice versa, evaluation of her ability to walk 10 ft, toilet transfer, tub/shower transfer or go from sit to stand was not attempted due to her medical condition or safety concerns. Active diagnoses of anemia, hypertension, diabetes, hyperlipidemia(high cholesterol), Alzheimer's Disease, seizure disorder, depression; there were no diagnosis of PVD or any circulatory complications. Record review of CR #1's undated Care Plan revealed, Focus- risk of falls due to immobility, muscle weakness and diabetes; Problem- CR #1 will be free from injury; approach- encourage resident to use environmental devices such as hand grips, handrails etc. Problem start date of 06/13/25- CR #1 has a diabetic ulcer to the left great toe; Goal target date 09/13/25- resident's wound will decrease in size with no complications as evidenced by wound documentation; Approach start date 06/13/25- nurse to complete wound documentation daily, refer to wound care doctor as needed, wound team to evaluate wound(s), treatments and healing status weekly. Problem start date of 06/16/25- CR#1 has trauma to left great toe; Goal target date: 09/16/25- wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained; Approach start date: 06/16/25- CNA to inspect skin, especially over bony prominences, during bathing and personal care. Nurse to complete wound observation weekly. There was no mention of podiatry care or services or her vascular disease.Record review of CR #1's Physician Orders revealed, Start Date 09/18/24; Description- Consult: Podiatry, Ophthalmology, dental as needed .Record review of CR #1's Progress Notes from admission on [DATE] to discharge on [DATE] revealed, There was no Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 20 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0687 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some documentation that CR #1 received podiatry care while at the facility with the following relevant entries.-06/12/25 at 11:27 PM signed by LVN D: upon assessment, the resident's left great toes appears bruised. No signs or symptoms of pain noted. Foot pulses were felt, no sign of compromised circulation. Foot is warm and dry to touch.-06/13/25 at 02:06 PM signed by Wound Care Nurse A revealed, nurse informed writer that patients left great toe appears to have bruising, writer assessed and observed a diabetic ulcer to left, great toe 08X0.5cm, no exudate, no odor or s/sx of infection, no pain. cleansed with normal saline, patted dry with sterile gauze, applied skin prep and left open to air. Called and spoke with patient's family and discussed the assessment and plan of care.-06/15/25 at 07:05 AM signed by LVN Dduring morning rounds, the aired reported that CR #1's big toe appeared to be bleeding and bruised. Upon assessment, observed active bleeding from the toe, with bruising extending up the foot and lower leg. Resident verbalized pain upon palpation of the affected area. NP notified for further evaluation and management.- 06/15/25 at 07:05 AM signed by LVN D- NP ordered STAT Xray to the affected toe and leg-06/16/25 at 05:34 PM signed by Wound Care Nurse B, nurse reported CR #1's left great toe has bruises and bleeding. Upon assessment, noted trauma to left toe measuring 1.2X2X0.1 cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection. NP made aware, wound cleaned with normal saline, pat dry with sterile gauze, applied Bactroban (antibiotic ointment) and covered wound with gauze, procedure tolerated by patient. Requested for podiatry service to the Social Worker-06/16/25 at 05:46 PM signed by RN A- X-ray of the left foot was completed during this shift in response to an existing wound. Resident tolerated the procedure without any complications. Left foot wound remains covered with dressing intact; no signs of active bleeding, or foul odor noted. Awaiting radiology results at this time.-06/16/25 at 06:25 PM signed by RN A- C-ray results were received and reviewed by NP as negative for fracture. -06/17/25 at 04:31 PM signed by Wound Care Nurse A- CR #1 family stopped by the office to ask questions regarding resident wounds, family was informed that patient has a diabetic ulcer to the left great toe and its being treated with skin prep daily and left open to air, trauma to the left great toe and it's being treated with Bactroban and covered with gauze daily, patient has been added to the podiatry list by the Social Worker and the WCD will be rounding on Thursday and will further assess patient's wounds and family will receive a weekly call with an update. Family expressed concerns of patient getting gangrene due to past experience of getting the right leg amputated and wanted to send patient out to get antibiotics. Family educated on the use of Bactroban ointment and informed and no s/sx of infection observed at this time, but Wound Care Nurse A can only give information on the assessment of wounds and the treatments put into place by the WCD via telehealth.06/17/25 at 06:35 PM signed by RN A, CR #1 noted with a diabetic wound to the left foot. During a family visit today, the resident's family expressed concern that the foot might be infected and requested that the resident be transported to the emergency room for further evaluation. Upon assessment, no signs or symptoms of infection were noted. Contacted EMS for non-emergency transportation, resident transported to the hospital for further evaluation.Record review of CR #1's Point of Care History from 09/17/24 to 06/17/25 revealed, no documentation of toenail care to CR #1.Record review of CR #1's Shower Sheets from 09/17/24 to 06/17/25 revealed, the only documented nail care was on 05/29/25 and no clarification was made if it was finger or toenail care. Record review of CR #1's Wound Management Detail Report dated 06/22/25 revealed there were no previously documented wounds prior to 06/13/25:06/13/25 at 11:16 PM signed by Wound Care Nurse A: Wound Type: Diabetic Ulcer; Wound location left big toe; 0.8X0.5 cm, with no odor or drainage; depth of injury- through the dermis (skin) and down to the subcutaneous (under the skin) tissue, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 21 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0687 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some muscle.06/16/25 at 06:08 PM signed by Wound Care Nurse B: Wound Type: Trauma; Wound Location: Left big toe; to left great toe measuring 1.2x2x0.1cm with moderate bright red sanguineous exudate (bloody fluid), mild swelling noted, purple discoloration to left great toe extending to foot, no odor, no s/sx of infection.Record review of CR #1's Physician Order dated 06/16/25 revealed, PRN wound treatment. Trauma to the left great toe; cleanse with ns apply sterile gauze and Bactroban (topical antibiotic) and cover wound with gauze as needed.Record review of CR #1's NP Progress Note dated 06/16/25. During the weekend nursing report of bruising and pain left first toe unclear how this happened. STAT x-ray ordered, wound care team following applied Bactroban. Physical Exam-Skin: Extremities- right AKA, left first toe swelling and tenderness; Musculoskeletal: :left first toe tenderness swelling and bruising, right AKA. Left first toe open wound minimal drainage/no bleeding. Diagnosis/Assessment and Plan left first toe swelling and report of some bleeding during the weekend, wound care team following, trauma wound left great toe unclear how this happened. Discussed with the wound doctor. xray shows no fracture. Open wound- left great toe trauma wound nailbed, wound care team following continue care treatments monitored closely. Left great toe pain likely due to trauma wound, ordered Acetaminophen 650 mg twice daily for 7 days and monitor.Record review of CR #1's Final X-ray Report dated 06/16/25 at 03:13 PM revealed, negative for acute disease, mild bone weakening and degenerative changes present.Record review of an undated investigation summary signed by ADON A revealed, on 06/12/25 LVN A observed what appeared to be bruising to the left great toe of CR #1 and then on 06/15/25 she observed active bleeding to the left great toe, bruising extending from the upper foot to the left lower leg and pain when touched. LVN D notified the NP who gave a STAT order for c-rays of the left lower extremity. On 06/16/25, she interviewed CNA D, CNA K, CNA N, CNA AC, and none of them knew how the resident was injured or saw anything out of the ordinary with the resident's toes.Record review of CR #1 Hospital Records dated 06/17/25 revealed, CR #1 had a right foot diabetic foot ulcer in 07/2024 and then an above the knee amputation. She presented with left first toe ulceration and discharge and her final admitted diagnoses were toe infection and gangrene (death of body tissue due to lack of blood infection or a serious infection) of the toe. Record review of CR #1's Hospital Hospitalist Consult dated 06/18/25 revealed, CR #1 had a PMH of significant dementia, diabetes, hypertension, high cholesterol, severe PAD (vascular disease in which narrowing of the blood vessels result in the limbs not receiving oxygen), right heel wound with AKA who presents with left foot wound. Record review of CR #1 Hospital Podiatrist Consult dated 06/18/25 revealed, gangrene over 50% of the left foot, acute signs infection extending from the big toe to the middle of the top of his foot, with minimal pulses in the foot and pain when touching the big left toe. Record review of CR #1's Internal Medical Progress Note dated 06/18/25 revealed, left big toe with dry gangrene with variating tone skin changes extending to the ankle. Record review of CR #1's Hospital Vascular Surgery consult dated 06/19/25 revealed, left 1st toe with dry gangrene with no drainage, redness on the top of the foot and no withdrawing with pain when touched. Record review of CR #1's Hospital Vascular Ultrasound dated 06/20/25 revealed, significant blockage of blood flow to the lower leg and foot. Record review of CR #1's Hospital Podiatrist Consult dated 06/23/25 revealed, CR #1s left food infection had improved. Extensive conversation with multiple family members at bedside, although no urgent findings in the lower extremity, concerns for gas and osteomyelitis are stable within the digit and no systemic signs of infection. Given contralateral amputation, gangrene with vascular disease on clinical exam, patient in need of leg amputation. However, since family refuses amputation, conservative treatment options are unlikely to be successful without improved arterial flow to the foot. Record review of CR #1's Hospital Infectious Disease consult dated 06/24/25 revealed, without an amputation, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 22 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0687 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some conservative treatment options are unlikely to be successful especially in the setting of impaired arterial blood flow. Record review of CR #1's Hospital Palliative Care Consult dated 06/24/25 revealed, CR #1's family decided against leg amputation as was recommended as they do not believe that it would improve her quality of life and would likely cause her to suffer. The family discussed alternatives to pursuing leg amputation, and hospice was discussed as a way to provide CR #1 care to keep her comfortable. Record review of email communications between the Social Worker and Medical Records dated 07/09/25 revealed, CR #1 had no documented visits or services with podiatry.An observation of pictures of CR #1's left foot dated 06/13/25 at 03:14 PM revealed, resident's foot was dry and flaky. Toenails on her three lesser toes were long and curled around the tip of her toes; with an appearance that they had not been cut for months. Bruising was observed to the upper foot by the great toe and a thick deep callus with a dark/black hole in the center. Her great toenail was thickened and yellow but attached to the nail bed.An observation of texts and pictures of CR #1's foot dated 06/15/25 taken by LVN D sent to Wound Care Nurse A revealed, [CR #1's] toe kind of look worse and its bleeding. The picture revealed the CR #1's toenail bleeding in the right upper corner and under the nail, with her nail elevated off the nail bed.An observation of pictures of CR #1's left foot dated 06/16/25 at 06:33 PM revealed, the skin on the tip of her left toe to be open. The wound to the tip was shiny and red, with dry blood on the nail bed under the nail. He left great toenail appeared to be lifted off the nail bed with visible dry black blood under.An observation of pictures of CR #1's left foot dated 06/17/25 at 04:24 PM, CR #1's left great toenail was lifted from the nail bed.In an interview on 06/22/25 at 10:45 AM, Family Member #1 said on Friday 06/13/25 the facility notified CR #1's family that the resident had a diabetic foot ulcer but there were no issues. The facility staff said the facility would treat the ulcer and reassured the family that it was basic and normal and at 3 PM the following Friday the podiatrist would visit CR #1. Family Member #1 said on 06/16/25 the facility then notified them that the foot was bleeding so she came to the facility and saw the resident. Family Member #1 said on 06/17/25 when she went to see CR #1 facility staff could not tell them if and when the podiatrist was coming. She said Wound Care Nurse B said CR #1's wound was treated with Bactrim (topical antibiotic) and CR #1 now had a foot ulcer and an injury to the toenails. Family Member #1 said she suspected something happened over the weekend based on how the area deteriorated. They said CR #1's right foot was previously amputated after a similar situation so she was concerned the resident had gangrene and demanded CR #1 be sent to the hospital for treatment. Family Member #1 said CR #1's hospital physicians said the resident had osteomyelitis (bone infection) and must have had it for a while so she required an AKA. They said the family had asked for an oral antibiotic in the facility but their request was denied and the hospital physician said the topical antibiotic used by the facility would not have made CR #1's foot infection better. Family Member #1 said the hospital gave the family 2 options, hospice or an amputation, and since an AKA would worsen CR #1's quality of life so the family decided to place the resident on hospice care. An observation on 06/22/25 at 05:00 PM revealed, CR #1 lying in a hospital bed. The resident had no leg on the right side and her left foot was surrounded with a dressing, the tip of her great toe was exposed and red irritated skin with a circular callused area visible. CR#1 was confused and non-interviewable; she reference people and things that were not in the room. In an interview on 06/22/25 at 05:15 PM, the Hospital Nurse said CR #1 suffered from a diabetic ulcer and an injury at the toenail. She said the nail appeared to be partially detached from the nail bed from suspected trauma but there was no indication of pain.On 06/26/25 at 06:09 PM, Family Member #1 notified the surveyor via text message that CR #1 had been transferred to another facility from the hospital to receive hospice care. In an interview (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 23 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0687 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some on 07/08/25 at 02:41 PM, the Hospital Podiatrist said CR #1 had significant history of PVD that resulted in her having an AKA on her right leg in 08/2024, and her vascular disease was so significant it caused her severe dementia. He said a resident with history of diabetes, PVD and a previous AKA should have had routine podiatrist visit. The Hospital Podiatrist said in the hospital CR#1 was diagnosed with osteomyelitis (bacterial bone infection) that needed to be treated with IV antibiotics in order to save the limb. He said routine podiatry would have prevented the acute traumatic event (toe infection) but due to her extensive PVD, CR#1 would have eventually needed an amputation in the future. The Hospital Podiatrist said from what he saw CR #1's left great toenail was lifted from the nail bed but there was no active or raging infection visible, the resident's WBCs were normal, and she did not have a fever during her entire stay. He said since an AKA would not better the CR#1's quality of life and the residents significant dementia, CR #1's family decided to place her on palliative (end of life) care. In an interview on 07/09/25 at 10:43 AM, Wound Care Nurse B said when she saw CR #1 on 06/16/25 she had a left great toe arterial ulcer and dried blood on her nailbed. She said Wound Care Nurse A had previously contacted the doctor, so she did the treatment for the day and CR #1's big toe had no active bleeding, but it was purple. Wound Care Nurse B said after treatment she requested a podiatry consult for the resident and CR #1 never had any podiatrist services prior to her request on 06/16/25 and the Social Worker was responsible for ensuring residents received podiatry services. She said she did not know how CR #1 suffered from the injury to her nailbed, but LVN D would be the best person to talk about the initial injury. In an interview on 07/09/25 at 11:04 AM, the Social Worker said she facilitated podiatry services for facility residents. She said anyone with feet could receive podiatry services but often not skilled because of funding, since the services will come from their pool of money, unless the resident had issues with their feet. The Social Worker said some issues that trigger podiatry services were ingrown or thick and long toenails, and if a resident had these issues she would ask their family/RP if they would like podiatry services and if they said yes she would send a referral to the podiatrist She said a resident with diagnoses of vascular disease, diabetes and a previous AKA should have been followed by Podiatry, she said she was notified by nursing staff on 06/16/25 and she put in a podiatrist referral but CR #1 went to the hospital the next day so she was never seen by a podiatrist. The Social Worker said only nurses were allowed to cut the nails of diabetics but after looking at the picture of CR #1's toenails she said facility nurses would not touch that, that would be podiatry and based on the picture CR#1 should have received podiatry care. She said after reviewing CR #1's chart there was no evidence to show the resident received podiatry care from admission till discharge and she had no records of placing a podiatry referral. The Social Worker said she did not remember being notified by a floor nurse or wound care nurse that CR #1 required podiatry services, and she does not know about referrals unless notified by the facility staff or family. In an interview on 07/09/25 at 11:39 AM, Wound Care Nurse A said CR #1 had a diabetic foot ulcer/callused area on her left great toe and she found out about in on the day she assessed it (06/13/25). She said the first day she saw it, the area was dry and callused, and it had been there for a while but there was nothing for her to follow at the time. Wound Care Nurse A said a resident that had a chronic area like what she observed on CR #1 should have been referred to podiatry and she did not recall the ulcer/callus being on CR #1's foot on admission so it was facility acquired. She said nurses do weekly skin assessments while the wound care nurse does the admission and readmission skin assessments, and they should always document what they saw. After reviewing the CR #1's chart Wound Care Nurse A said the first documentation of the left toe area of concern post admission was documented by 01/29/25 signed by LVN T and she should have notified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 24 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0687 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some wound care team because diabetics wound injuries can be progress to a diabetic foot ulcer so they could watch it. She said diabetic foot management was important because diabetics can have prolonged wound healing, which could impact circulation, and a high-risk infection and podiatry should be involved because that was what they specialize in. Wound Care Nurse A said CR #1 should have been followed by podiatry based on her history and how her toes looked. She said based on the pictures of CR #1's toes between 06/13/25 and 06/16/25, the residents toenails appeared that she had not received nail care for a period she cannot say and based on the appearance of her toenails podiatry would have been responsible to cut CR #1's nails. Wound Care Nurse A said she did not know if CR #1 received podiatry services prior to her being alerted in June but she was placed on the list once she became aware. She said a podiatrist was required to cut resident's like CR #1's to prevent infections. Wound Care Nurse A said the facility podiatry protocol started when a floor nurse notified the wound care nurse of a foot concern, after the wound care nurse assess the resident, they notified the social worker who would then put in the referral and notified the physician who would then round on the resident. She said to her knowledge the facility protocol to request a podiatry referral was not followed because she was never notified of CR #1's foot concern. Wound Care Nurse A said podiatry care in residents like CR #1 was important to prevent the long nails that can become imbedded or snag leading to trauma. She said a resident with PVD who had unaddressed foot care could result in infection, gangrene and ultimately infection, Wound Care Nurse A said CR #1 had 2 issues with her big toe, when she first saw her it was suspected trauma to the big toe, there was discoloration to the top of the foot and blood on the edge of the nail but she had no idea how the trauma occurred. She said it looked like CR #1 snagged her left on something. Later on, CR #1 suffered from a diabetic foot ulcer on the tip of her great toe. In an interview on 07/09/25 at 12:20 PM, Wound Care Nurse B who was acting as the Interim DON at the time of the interview said the wound care team was never notified of any concerns to CR #1's feet prior to 06/13/25. She said when a resident had PVD and diabetes there was a concern that any wound could lead to a severe infection and with insufficient oxygen it can lead to necrosis (tissue death), so special focus should be placed on foot care. She said any toenail care provided to residents with extensive PVD, diabetes, or thick fungus nails should be provided by podiatry and CR #1's records showed had no documentation of any toenail care. Wound Care Nurse B said unkempt nails, can lead to scratches & wounds, and if the nail snagged on something it could result in trauma. Wound Care Nurse B said there were 2 different problems on CR #1's great toe, the 1st was a callus that had been there for a while that developed into an ulcer and then there was some kind of trauma but no one in the facility knows how it happened. She said the NP saw CR #1 and said the resident had suffered from trauma to her great toe. She said improper foot care in a resident with extensive PVD, diabetes and AKA could lead to worsening of a wound, improper circulation causing infection, necrosis, osteomyelitis and eventually amputation if not properly treated. In an interview on 07/09/25 at 12:35PM, the MD said CR #1 had extensive vascular disease and had an avulsed toenail (when toenail is partially or completely torn away from the nail bed). He said it looked like the toenail got hit on something and suffered some sort of trauma. The MD said the expectation for a resident like CR #1 who had vascular disease, diabetes and a previous AKA was for their foot or feet to get continuous evaluation by nursing to identify and issues. He said residents with vascular disease and diabetes should be followed by podiatry because they can trim resident nails without damage to reduce the risk of infection. The MD said infection was a concern in residents with PVD because they do not have adequate blood floor to the feet to take care of the infection and if not properly/timely treated could result in damage to the digit (toe), cellulitis (skin infection), sepsis (blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 25 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0687 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some infection) and gangrene. He said his expectation was that nursing staff should have notified the primary doctor and wound care nurse of any foot concerns so that the appropriate treatment would be started. The MD said prior to mid-June he was not aware CR #1 had any chronic foot ulcers/calluses and he did not know she had long toenails or needed podiatry services because she was never on any list for any foot concerns. In an interview on 07/09/25 at 12:59 PM, ADON A said she was the ADON on CR #1's Hall. She said she was never aware of or notified of anything/concerns on CR #1's toes. She said in residents like CR #1 with diabetes, vascular disease, and a previous AKA nursing staff were concerned about feet especially any discoloration, openings or change in tissues because they can lead to ulcers and wounds which were made worse due to the resident having bad circulation. ADON A said infections in residents with PVD can lead to major wounds and ultimately amputation, so nail care was especially important to prevent scratches or other trauma. She said the Podiatrist was responsible for nail care in residents like CR #1 and their services were initiated when a CNA or family notify nursing administration of the residents need for podiatry services. ADON A said she was never notified that CR #1 needed podiatry services, and prior to June she was unaware CR #1 had a scabs, bruising, calluses, or areas of concerns on her toes. She said LVN T never alerted her of any concerns to her toes. ADON A said based on the record she reviewed and the presentation of CR #1 the area of concern documented for the 1st time on LVN T's documented skin assessment on 01/29/25 should have been a CIC and CNAs should have documented on the residents toes which included toenail length or the presence of any injuries/calluses etc. After looking at the pictures of CR #1's left great toe on 06/13/25 & 06/16/25, ADON A said she was never aware of anything like what the pictures showed until after CR #1 discharged from the facility. She said she investigated the trauma CR #1 suffered to her toenail between 06/13/25 and 06/16/25 and none of the nursing staff was aware of how the trauma occurred. ADON A said in the pictures presented it appeared CR #1 had not received nailcare for several months as the nails appeared to be double that of the nailbed with the 2-4th toenails curing around the tip of her toes. She said it was never on their radar that CR #1 had not received podiatry care while at the facility. In an interview on 07/09/25 at 01:22 PM, the NP said she was notified over the weekend (06/13 to 06/15/25) that CR #1 had bruising to her toe and foot, so she ordered and Xray of the foot which came back as negative for any acute findings. She said when she saw CR #1 on 06/16/25 the resident was experiencing pain and, there was an open area with a scab to her great toe. The NP said the wound care nurse already spoke to the wound care doctor and ordered a podiatry consult but no one knew what happened. She said there was bruising on the toes and foot, minor swelling, no drainage or other signs of infection and CR #1's left foot particularly the toe appeared to have suffered trauma. The NP said residents with diabetes, PVD and a previous AKA were expected to have their feet monitored for infection and receive podiatry follow up monthly to prevent infection that could lead to osteomyelitis. She said CR #1 was one of her residents and she did not have any wounds or areas of concern prior to mid-June. The NP said the first time she saw CR #1's feet she had concerns it was a fracture, the resident had a dry wound, but the resident's family was very concerned because this was how CR #1's right side AKA started and wanted her to go to the hospital for treatment. She said she did not think that CR #1 needed to go to the hospital at the time because it looked like bruising from trauma not cellulitis. The NP said she did not know that CR #1 had not received podiatry services from admission but after she saw her, she was referred to podiatry. In an interview on 07/09/25 at 03:33 PM, CNA K said she sometimes provided care to CR #1, and she was not aware of any wounds at the tip of her toes.In an interview on 07/09/25 at 04:23 PM, LVN D said during daily rounds on 06/12/25 it looked like CR In an interview on 07/09/25 at 04:23 PM, LVN D said during daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676450 If continuation sheet Page 26 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0687 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete rounds on 06/12/25 it looked like CR #1 had stubbed her toe, it was light red, so she documented it and notified the wound care nurse. She said CR #1's toe appeared the same the next day but on the following day it looked like it was bleeding, so she texted the NP. LVN D said she worked with CR #1, and she thought the resident had a circular scab on the tip of her toe, but she cannot say if it was the chronic scab she documented on her weekly skin assessments, she said I always just saw it on her toe. LVN D said diabetics were expected to have weekly observations with emphasis on their feet, but she never notified anyone of the chronic scab on CR #1's foot because she thought the facility was already monitoring it, so it was not a change of condition and CR #1's nails were fine they were not long. LVN D said nurses performed toenail care and she could not think of the top of her head which residents required a podiatry referral but from what she could remember CR #1's toenails were normal and did not require a podiatrist. She said long toenails in a diabetic resident with vascular complications could lead to the nail splitting, getting snagged, damage, infection and if untreated it can quickly turn into a complicated situation leading to amputation.In an interview on 07/10/25 at 02:32 PM, Wound Care Nurse B who was the interim DON at the time said neglect was the failure to provide care for the resident. She said prior to admission the MDS Nurse and DON reviews the resident's chart looking at diagnosis, present history, medication list, plan and therapy needed to ensure the facility was able to meet the resident needs. Wound Care Nurse B said failure to provide services was neglect, which could result in deterioration/worsening of health conditions, untreated health conditions, infections, and other conditions. She said based on CR #1's diagnosis she should have had a podiatrist evaluation and been followed by the podiatrist based on her diagnosis of diabete Event ID: Facility ID: 676450 If continuation sheet Page 27 of 28 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 676450 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terra Bella Health and Wellness Suites 12262 Cityscape Ave Houston, TX 77047 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 medication carts (100 Hall Nurse Cart) reviewed for medication storage . - LVN D failed to ensure the 100-200 Hall Nursing cart was locked when not under direct supervision of authorized staff. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications.Findings included: An observation on 07/10/25 starting at 08:55 AM revealed, an unlocked and unattended nursing cart in front of room [ROOM NUMBER] and #115. The back of the cart was pushed against, and the drawers were exposed to the hallway. At 09:00 AM LVN D walked from behind the double doors that led to the hall with the dining area and kitchen and walked up to the unattended cart.In an observation and interview on 07/10/25 at 09:01 AM, inventory of the 100 Hall Nurse Cart with LVN D revealed,Drawer 1- OTC medications, syringes, prescription medication, > 30 lancets (a device with a small needle used to prick fingers to collect blood for blood sugar monitoring.), >100 pen needles (needles attached to insulin pens).Drawer 2- liquid OTC and RX Only medications, solid form Resident prescription medications.Drawer 3- inhalation solutions, inhalers, and topical creamsLVN D said nursing carts should be locked when unsupervised to prevent unauthorized access to the carts contents. She said unlocked carts could place residents at risk of injury and adverse drug reactions if they consumed medications from the cart. LVN D said she left her cart unattended because she was interrupted by a resident request during medication pass.In an interview on 07/11/25 at 09:29 AM, Wound Care Nurse B who was acting as the Interim DON at the time said nursing carts were to be locked when unsupervised to prevent unauthorized access by residents especially the cognitively impaired. She said unlocked nursing carts could place residents at risk for adverse drug reactions and overdose.Record review of the facility policy Medication Management revised 07/01/16 revealed, Security and Safety Guidelines: 1. Staff who are not authorized or permitted into the Medication Room or having access to a medication cart, are supervised by authorized personnel when accessing for non-clinical reasons. 2. The Medication room is always locked when not in use and in direct line of sight. 3. The medication cart is locked when not in use and in direct line in sight. 4. Keys to the medication room and cart are kept with the authorized staff and are the responsibility of the person assigned those keys. Event ID: Facility ID: 676450 If continuation sheet Page 28 of 28