Health inspection·February 2, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's face sheet revealed an [AGE] year-old female who was admitted on [DATE]. Her diagnoses were Fracture of lower end of left ulna, Effusion Right Knee, Cerebral Infarction and Dementia, Record review of Resident #2's MDS dated [DATE] revealed Resident #1 had a BIMS score of 11 out of 15 indicating she was moderately cognitively impaired. MDS Section G indicated Resident #1 was total dependence for bathing with one-person physical assist for bathing. Record review of the care plan revised on 2/1/23 read in part . Resident #2 has a self-care performance deficit r/t left arm fractur and dementia; Bathing/Showering: Avoid scrubbing and pat dry sensitive skin. Requires total assist of one staff. Bed Mobility: Requires extensive assistance of one staff. Personal Hygiene Routine: Requires extensive assistance of one staff . Record review of Resident #2's shower schedule dated 1/26-2/2/23 revealed 8's on shower sheet indicating Resident #1 did not receive showers from 1/23 to 1/31/23. Observation and interview on 1/31/23 at 9:30 am with Resident #2, she said she asked about a shower today because she felt dirty. She said she could not remember when she had a bath. Her hair was oily and disheveled. Resident #3 Record review of Resident #3's face sheet revealed an [AGE] year-old female who was admitted on [DATE]. Her diagnoses were Chronic Obstructive pulmonary Disease, Acute Respiratory Failure, Cirrhosis of Liver, Multiple Fractures of Ribs Associated with Chest Compression and Cardiopulmonary Resuscitation. Record review of Resident #3's Care Plan revised on 1/25/23 read in part . The resident has a self-care performance deficit related to weakness from recent respiratory failure. Goal: Will Improve current level of function in transfers and completing her ADLs by the next review.; Bathing/Showering: Avoid scrubbing and pat dry sensitive skin, requires total assist of one staff; Bed Mobility: Requires extensive assist of one staff . Record review of Resident #3's shower schedule dated 1/26-2/2/23 revealed 8's on shower sheet indicating Resident #3 did not receive showers from 1/26-2/2/23. Observation and Interview on 2/1/23 at 9:55 am with Resident #3 revealed the Resident was laying on left side in bed. Her hair looked oily and disheveled. She said she had not received a bath or shower since she arrived at the facility the Friday of last week. She said she was supposed to get one yesterday, but it didn't happen. She said she had her family come to see her, and her family knew the facility had not provided a shower on her scheduled shower day. Interview on 2/1/2023 at 7:54 am with CNA B, she said the residents would be upset when they don't get showers. She said she used the shower list to provide residents with showers. She said if residents were not on the schedule, she would let them know she had a shower list and she would try to fit them in, but they would be considered as a second priority because all rooms were on a schedule. She said showers should be documented on the facility's resident clinical database. She said she could not say why Residents, 1, 2, and 3 did not get showers for weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676454 If continuation sheet Page 2 of 10 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 676454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 2/1/2023 at 8:54 am with CNA A, she said showers schedules were scheduled according to rooms A or B. She said showers were provided in the morning or afternoon. She said she provided residents with showers but had not today. She said the CNAs were supposed to provide residents with showers twice a week. She said CNAs were supposed to document they provided a shower to the resident in the facility's resident's clinical database. She said she could not say why Residents, 1, 2, and 3 did not get showers for weeks. She said If someone was not showered it could lead to a decline in personal hygiene and could lead to risk of infection. Interview on 2/1/2023 at 8:25 am with the DON, she said she was not familiar with the facility's ADLs policy. She said she ensured residents received showers twice a week, morning, or afternoon, according to their shower schedules. She said if someone came from hospital, the nursing staff would not necessarily bathe them right away, but they should offer a shower or bath. She said CNAs should be shaving residents because it was a part of grooming. She said residents would sometimes refuse but, it should be documented on the facility's resident's clinical database when residents refused baths/showers. She said she could not say what the negative outcome would be to residents who don't receive showers in accordance with their shower schedule. Interview on 2/1/2023 at 4:05 pm with MDS Nurse, she said scheduled showers for residents were supposed to be twice a week depending on what room or bed (A or B). She said if residents requested more frequent showers their request would be honored. The 8's on the Documentation Survey Report mean the Care was not performed. She said if residents complained of not getting their showers, they would get placed on the shower schedule for same day, but they would be considered as second priority. She said second priority meant that residents would get showers if there was enough time to get residents that were on their routine shower days showered. She said the facility staff had certain rooms they routinely visited during the week, and they were required to initial Care Plan meeting. She said the IDT had not had complaints regarding residents not receiving showers. She said the negative outcome for residents who do not get showered or bathed was body odor, skin breakdown, infection, and cellulitis. She said, there are many outcomes for not being bathed. In a follow-up interview on 2/2/2023 at 9:00 am with the DON, she said she doesn't understand what went wrong with residents not getting showers on their scheduled shower days. She said the CNAs told her they informed the nurses when residents refused baths, but she recognized there was no documentation regarding resident showers on the facility's resident's clinical database which was the reasons why she in-serviced staff yesterday. She said she did not realize residents were complaining they had not had baths or showers. She said residents not being showered had been an issue in the past and she conducted in-services with staff. She said she it was important to provide showers especially to residents who had dementia as a diagnosis because they could not communicate when they were dirty or felt dirty. She said the DON was responsible to ensure nursing staff were bathing or showering residents twice weekly. Record review of the facility's ADL policy titled, Activities of Daily Living, not dated, read in part . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676454 If continuation sheet Page 3 of 10 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 676454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #234) reviewed for incontinent care. -The facility failed to ensure Resident #234's Foley catheter tubing (tubing inserted into the bladder to drain urine) was secured to her leg to prevent stress or pulling on the catheter site. -The facility failed to ensure LVN D and CNA A followed proper infection control procedure by prevented Resident # 234 Foley bag and tubing from touching the floor. These failures could place residents at risk for pain, infection, injury and hospitalization. Findings include: Record review of Resident #234's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #234 had diagnoses which included obstructive and reflux uropathy (obstruction preventing urine to flow), dementia (impairment of brain functions such as memory loss and judgment), cerebral infarction (disrupted blood flow to the brain). Record review of Resident #234's admission MDS, dated [DATE], revealed a BIMS score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Resident #234's functional status revealed she required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #234's urinary continence was not rated due to indwelling catheter. Record review of Resident #234's care plan, dated 02/01/2023, revealed: Focus: Resident #234 admitted with an indwelling foley catheter due to obstructive uropathy. She was at risk for falls over tubing and infection; Goal: The resident will be and remain free from catheter-related trauma through the review date; Interventions: Check tubing for kinks and ensure that collection bag was not touching the floor upon routine rounds; Monitor and document for pain or discomfort due to the catheter. Observation on 02/01/2023 at 11:30 AM during catheter care for Resident #234 by CNA A and CNA B revealed her foley catheter tubing over her right leg not secured in place with a leg strap. Interview on 02/01/2023 at 12:04 PM, CNA A stated Resident #234 did not have a leg strap on during the catheter care. CNA A stated the resident was supposed to have a leg strap on to secure the tubing. CNA A stated the risk of the resident not having a leg strap was the catheter will move and pull on the resident. The CNA stated the nurse was the one responsible for making sure there was a leg strap on the resident. CNA A stated she will notify the nurse right now. CNA A stated she was not sure why she was not wearing one. Interview on 02/01/2023 at 12:12 PM, CNA B stated Resident #234 needed to have the leg strap on to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676454 If continuation sheet Page 4 of 10 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 676454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prevent the tubing from pulling and moving. CNA B stated Resident #234 did not have the leg strap on. The CNA continued and stated the nurse was the one responsible for making sure the resident had the leg strap for the catheter. Interview on 02/01/2023 at 12:19 PM, LVN D stated the CNA just reported to her Resident #234 did not have the catheter leg strap on, but they were getting one for her now. LVN D stated she was not sure why the resident's catheter was not secured with a leg strap. LVN D stated the catheter strap was important because there was a risk of the catheter pulling, moving, and hurting the resident. Interview on 02/01/2023 at 3:06 PM, the Interim DON stated her expectations for catheters was they were to be secured with leg strap. She continued and stated the risk was the catheter could pull and cause trauma. The Interim DON stated it was the responsibility of both the CNA and the nurse to put on the leg strap. The Interim DON stated the CNAs do catheter care, if they see there was no strap they should put it on. She stated the nurse was also responsible for ensuring there was a strap.The Interim DON stated the Plan was to in-service to make sure the CNA know they can also replace the leg strap. Interview on 02/02/2023 at 8:33 AM, the Administrator stated her expectation was that the catheters were secured in place. The Administrator stated she did not know why this occurred; the staff was normally very good about making sure the catheter straps were on. She continued and stated the risk of not securing the tube was it could result in infection or trauma. Observation on 02/01/23 at 7:41 a.m. revealed that Resident #234's Foley bag and the tube were touching the floor. Observation and interview on 02/01/23 at 7:50 a.m., LVN D said Resident #234's Foley bag and the tube were on the floor. She said both of the Foley parts should not touch the floor because the floor had germs, which could travel into Resident #234's bladder and cause the resident to get an infection (UTI)which was infection control. LVN D said she had a skill check-off on foley care with her agency, and the DON talked to her about infection control on her first day at the facility. She said the charge nurse monitored the aides and made sure the residents were provided care, and she did not pay attention or did not notice the Foley bag and tube were touching the floor. Interview on 02/01/23 at 12:03 p.m., CNA A said she was Resident #234's aide and did not notice the Foley bag and tube were touching the floor when she checked on Resident #234 early this morning when she made rounds. CNA A said the Foley bag and the tubing should be off the floor to prevent contamination of the Foley because it was an infection control issue. CNA A said if the bag became contaminated because it touched the floor, the germs could get into Resident #234's bladder, and the resident could get UTI. she said she had Foley care skill check-off, and the nurse monitored the aides and made sure the aides were proving care for the residents. Interview on 02/01/23 at 2:57 p.m., the MDS coordinator said Resident #234's Foley bag and tubing should not have touched the floor because of infection control. She stated CNA A and LVN D should make rounds and ensure no part of the Foley was touching the floor. She said the Foley touching the floor could pick up germs and give Resident #234 an infection if it traveled to the bladder. The MDS coordinator said the nurse and aide had competency check-off and in-service on Foley care. Interview on 02/02/22 at 10:54 a.m., the Interim DON said Resident #234's Foley bag and the tube should not touch the floor to prevent the bag and the tube from being contaminated germs which could (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676454 If continuation sheet Page 5 of 10 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 676454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few travel to Resident #234 bladder, and the resident would get an infection (UTI). She said the nurse monitors the aides and should ensure Resident #234's Foley bag and tube were off the floor. She stated CNA A was checked off on Foley care and LVN D was an agency nurse, and she had her skills check - off in the computer. Interview on 02/02/23 at 2:50 p.m., the Administrator said Resident #234's Foley bag and tubing should not touch the floor because of contamination, and the resident could get an infection. The administrator stated the nursing staff should ensure Resident #234's Foley should not touch the floor. Record review of the facility's policy titled Catheter Care Policy, dated 08/16/2017, revealed in part: .The purpose of this policy is to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder ad kidney infection . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676454 If continuation sheet Page 6 of 10 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 676454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493 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 0880 Provide and implement an infection prevention and control program. 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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 4 Staff (Housekeeper E, LVN D, and CNA A) reviewed for infection control. Residents Affected - Some -The facility failed to ensure Housekeeper E followed proper use of PPE and infection control procedure while cleaning the nursing station, clean utility room, restroom and cubby station in 200 hall. -The facility failed to ensure LVN D followed proper infection control on disinfecting equipment before and after it was used on Resident #234. -The facility failed to ensure Resident # 234 Foley bag and tubing from touching the floor. -The facility failed to ensure LVN D followed proper hygiene after she provided care for Resident #234. These failures could place residents at risk for infection, and reinfection. Findings include: Observation on 02/01/23 at 7:20 a.m. revealed Housekeeper E cleaned the nursing station between 200 and 300 hall. When she finished cleaning, she pulled the trash from the trash can in the nursing station and walked to her cleaning cart in 200 hall, two rooms from the nursing station. Housekeeper E placed the trash in the trash can on the cleaning cart. She did not take off the used gloves before she took a towel and bottle spray from the cart and walked into the clean utility room. Housekeeping still wore the used gloves and cleaned the counter, sink, microwave and picked up the trash from the trash can and walked to the cleaning cart and placed the trash bag in the trash can on the cart. Next, she took another spray bottle and other cleaning supplies and walked into the restroom in 200 hall, still wearing the same gloves, and she cleaned the restroom, brought out trash from the restroom, and disposed of it in the trash can on the cart. Housekeeper E then took off her gloves, placed it in the trash can attached to the cart, and did not wash or sanitize her hand before she took a roll of toilet paper and placed it in the restroom. When she came out of the restroom, she picked up trash from the can in the cubby station in 200 hall, walked to the cart, and placed it in the trash can. She then took a roll of trash bags from the cart and put it in the storage room. When she returned to the cart and started pushing the clean cart toward 300 hall, the surveyor intervened. Interview on 02/01/23 at 7:31 a.m., Housekeeper E said she forgot to take off her gloves and wash her hands after cleaning one area before going over to another site to prevent spreading germs from one area to another. She said she had contaminated the areas she cleaned with the same gloves, and if any resident came in contact with the areas, they could contract the germs and the resident could become sick. Housekeeper E said she was in-serviced on infection control, PPE, and hand washing. Interview on 02/02/22 at 9:11 a.m., the Housekeeping Director said Housekeeper E should wear gloves while cleaning the common areas and take off the gloves and wash or sanitize their hands before cleaning another area. She said Housekeeper E should not have worn the same gloves to clean multiple areas because she would be transferring germs from one area to another and any resident that came in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676454 If continuation sheet Page 7 of 10 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 676454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some contact with the surface could contact the germs and could become sick. She said the DON in-serviced serviced Housekeeper E with other facility staff on infection control, PPE, and hand washing. Interview on 02/02/23 at 12:41 p.m., the Administrator said, like everybody else in the facility, Housekeeper E should have washed or sanitized her hand and donned a clean glove before going over and cleaning another section. She said the housing monitored the housekeeper and ensure she followed proper infection control measures while cleaning the facility. The Administrator said washing and donning clean gloves should be done each time to prevent cross-contamination from one area to another. Resident #234 Record review of Resident #234's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #234 had diagnoses which included obstructive and reflux uropathy (obstruction preventing urine to flow), dementia (impairment of brain functions such as memory loss and judgment), cerebral infarction (disrupted blood flow to the brain). Record review of Resident #234's admission MDS, dated [DATE], revealed a BIMS score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Resident #234's functional status revealed she required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Resident #234's urinary continence was not rated due to indwelling catheter. Record review of Resident #234's care plan, dated 02/01/2023, revealed: Focus: Resident #234 admitted with an indwelling foley catheter due to obstructive uropathy. She was at risk for falls over tubing and infection. -Goal: The resident will be and remain free from catheter-related trauma through the review date. -Interventions: Check tubing for kinks and ensure that collection bag was not touching the floor upon routine rounds; Monitor and document for pain or discomfort due to the catheter. Observation on 02/01/23 at 7:41 a.m., LVN D took the blood pressure machine and pulse oximetry to Resident #234's room and checked her blood pressure and her oxygen saturation without disinfecting the equipment before and after use. She placed the blood pressure machine on top of the bedside table when she entered the room. After checking the resident's blood pressure, she placed the blood machine and oximetry on the resident's bed. When she came to the medication cart, she placed it on top of the cart without disinfecting the equipment and did not place a barrier on top of the cart to prevent contaminating the cart surface. Interview on 02/01/23 at 7:50 a.m., LVN D said she should have disinfected the blood pressure machine and pulse oximetry before and after she used it on Resident # 234 because it was shared equipment which was used on different residents. LVN D said the equipment was disinfected to prevent the transfer of any germ from one resident to another because it could put a resident at risk of becoming sick if the resident becomes contaminated with any germ from another resident. She said she was in-serviced on infection control with her agency. Interview on 02/01/23 at 3:25 p.m., the MDS coordinator said LVN D should have disinfected the blood pressure machine and the pulse oximetry before and after on Resident # 234. She said LVN D should had let the equipment dry before using it on another resident, and it would prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676454 If continuation sheet Page 8 of 10 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 676454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cross-contamination. The MDS coordinator said if the same blood pressure cuff were shared between residents was not disinfected, it could transfer germs from one resident to another, and the resident could become sick. Interview on 02/02/23 at 11:2 a.m., the Interim DON said LVN D should have disinfected the blood pressure machine and pulse oximetry before she used it to get vital signs from Resident # 234. The Interim DON also said any shared care equipment should be cleaned before and after use, before it could be used on another resident, to prevent the spread of germs and residents getting sick from other resident germs. She said the nurse managers monitor the floor nurses and ensure they follow the facility protocol during care to prevent any harm to the residents. Interview on 02/02/23 at 12:44 p.m., the Administrator stated LVN D should have disinfected the blood pressure machine and pulse oximetry before and after using it on Resident #234. She said it was done to prevent the spread of germs. She also stated if one resident had any infection, it could spread or be transferred to other residents if the equipment was not disinfected. Observation on 02/01/23 at 7:41 a.m. revealed that Resident #234's Foley bag and the tube were touching the floor. Observation and interview on 02/01/23 at 7:50 a.m., LVN D said Resident #234's Foley bag and the tube were on the floor. She said both of the Foley parts should not touch the floor because the floor had germs, which could travel into Resident #234's bladder and cause the resident to get an infection (UTI)which was infection control. LVN D said she had a skill check-off on foley care with her agency, and the DON talked to her about infection control on her first day at the facility. She said the charge nurse monitored the aides and made sure the residents were provided care, and she did not pay attention or did not notice the Foley bag and tube were touching the floor. Interview on 02/01/23 at 12:03 p.m., CNA A said she was Resident #234's aide and did not notice the Foley bag and tube were touching the floor when she checked on Resident #234 early this morning when she made rounds. CNA A said the Foley bag and the tubing should be off the floor to prevent contamination of the Foley because it was an infection control issue. CNA A said if the bag became contaminated because it touched the floor, the germs could get into Resident #234's bladder, and the resident could get UTI. She said she had Foley care skill check-off, and the nurse monitored the aides and made sure the aides were proving care for the residents. Interview on 02/01/23 at 2:57 p.m., the MDS coordinator said Resident #234's Foley bag and tubing should not have touched the floor because of infection control. She stated CNA A and LVN D should make rounds and ensure no part of the Foley was touching the floor. She said the Foley touching the floor could pick up germs and give Resident #234 an infection if it traveled to the bladder. The MDS coordinator said the nurse and aide had competency check-off and in-service on Foley care. Interview on 02/02/22 at 10:54 a.m., the Interim DON said Resident #234's Foley bag and the tube should not touch the floor to prevent the bag and the tube from being contaminated germs which could travel Resident #234 bladder, and the resident would get an infection (UTI). She said the nurse monitored the aides and should ensure Resident #234's Foley bag and tube were off the floor. She stated CNA A was checked off on Foley care and LVN D was an agency nurse, and she had her skills check - off in the computer. Interview on 02/02/23 at 2:50 p.m., the Administrator said Resident #234's Foley bag and tubing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676454 If continuation sheet Page 9 of 10 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 676454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493 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 0880 should not touch the floor because of contamination, and the resident could get an infection. Level of Harm - Minimal harm or potential for actual harm Observation on 02/01/23 at 7:44 a.m. revealed LVN D washed her hands after she administered medication to Resident # 234. LVN D turned off the water faucet with the same wet paper towel, she dried her hands. Residents Affected - Some Observation on 02/01/23 at 7:755 a.m., LVN D repositioned Resident #234 Foley off the floor then she washed her and turned off the water faucet with the same wet paper towel she dried her hands. Interview on 02/01/23 at 8:00 a.m., LVN D stated she had training with her agency on hand washing, and she should have turned the water faucet off with a clean, dry paper towel to prevent germs back to her clean hands. LVN D said she contaminated her hands, and if she had come in contact with the resident, she could transfer the germs to the resident, and the resident could get sick from the germs. Interview on 02/01/22 at 3:23 p.m., the MDS coordinator said LVN D should have used a clean, dry paper towel to turn off the tap so as not to leave germs on the water faucet to prevent the spread of germs. Interview on 02/02/23 at 11:00 a.m., the Interim DON said LVN D should have turned off the water faucet with a clean, dry paper towel after LVN D had dried and washed her hands. she stated LVN D should have used a dry paper because it would prevent the germs on the water tap from contaminating her clean washed hands. Interview on 02/02/23 at 12:54 p.m., the Administrator said LVN D should have dried her hands, trashed the wet paper towel, used a dry paper towel, and turned off the tap to prevent cross-contamination. Record review of the undated facility policy on cleaning and disinfection of resident care equipment not dated read . infection control principle to prevent spread of infection through contact with resident care equipment. Reusable resident care equipment is cleaned and disinfected . staff should follow established infection control principles for cleaning and disinfecting reusable . include blood pressure cuffs . Record review of the undated facility policy on infection control, standard precautions read . procedure #2c . before leaving . cubicle remove and discard PPE into the appropriate receptacle, followed by hand hygiene . #3d . wear a disposable medical examination group gloves for cleaning the environment. #3e remove gloves after contact with the surrounding environment, use proper technique to prevent contamination . Record review of the facility policy on hand hygiene dated 06/05/19 read . staff will perform hand hygiene when indicated, using proper technique . #5 hand hygiene technique when using water and soap . #5e dry hand thoroughly with single use towel . #5f use towel to turn off the faucet . Record review of the skill check off provided for CNA A revealed there was no skill check off for Foley care. Record review of the facility in-service on hand washing and sanitizing dated 12/13/22 revealed Housekeeper E's name was listed as one of the staff that was in-serviced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676454 If continuation sheet Page 10 of 10