Health inspection·May 15, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview and observation on 05/14/25 at 12:29 PM with Resident #4 revealed the resident lying in bed on the same bed linen. The resident's sheets still had not been changed. The resident reported her sheets had not been changed since last week (she could not remember the exact day that her sheets had been changed). She stated she was not sure how often the sheets were supposed to be changed, but reported she did not feel as though she should have to request for them to be changed. She stated the staff were supposed to change her sheets and make her bed, but reported it had not been done. The resident stated the residue on her sheets were chocolate. She stated the chocolate had been on her sheets since Friday of last week. Interview on 05/14/25 at 1:36 PM with CNA F revealed she checked on the residents every hour. She stated the CNAs were responsible for changing the residents' bed linen. She stated the linen was changed as needed, when they asked, and after showers. She stated the residents' shower days are every other day. She stated Resident #4's linen had not been changed. She stated she was not sure why the linen had not been changed yet. She stated the risk of the linen not being changed was bed sores or bugs, and possible infection, depending on what was on the sheet. She stated she did not change the resident bedding on yesterday. Interview on 05/14/25 at 3:38 PM with the DON revealed bed linen was expected to be changed on shower days and as needed. She stated the CNAs were expected to change bed linen when the shower techs were giving showers. She stated the risk of not changing bed linen would depend on what was in the bed. She stated she did not think there was a policy for bedding/linen changes. Interview on 05/15/25 at 3:08 PM with the Administrator revealed the CNAs were responsible for changing the residents' bed linen. She stated the resident's linen should be changed consistently with baths/showers, when soiled, wet or at the resident's request. She stated the risk of not changing linen, could cause rash as it promoted skin integrity. On 05/14/25 at 1:38 PM a facility policy for bedding/linen was requested but the Administrator reported there was no policy for bedding/linen. On 05/15/25 at 9:36 AM a facility policy for homelike environment was requested but the Administrator reported there was no policy for homelike environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the Center for Medicaid/Medicare System (CMS) System for 3 of 6 closed records (CR #1, #2 and #3) reviewed for Minimum Data Set (MDS) transmission. Residents Affected - Some CR #1, CR #2 and CR #3's discharge MDS assessment was not completed and transmitted within 14 days of CR's discharges. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required. The findings were: Record review of CR #1's Facesheet dated 03/20/2025 revealed CR #1 was a 79-years old male who originally admitted to the nursing facility (NF) on 11/15/2022 and readmitted on [DATE] and discharged on 02/03/2025. CR #1's diagnosis included but were not limited to non-st elevation (nstemi) (a type of heart attack that doesn't show the characteristic) myocardial infarction (a type of heart attack characterized by a partial blockage of a coronary artery, leading to reduced blood flow and heart muscle damage), presence of aortocoronary bypass graft (surgical procedure to improve blood flow to the heart), atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where the coronary arteries, which supply blood to the heart, become narrowed or blocked by the buildup of plaque), and heart failure (heart cannot pump enough blood meet the body's needs). Record review on 05/14/2025 at 10:14 a.m. revealed that CR #1's MDS discharge annual review date (ARD) had been due on 02/03/2025 and had been 86 days overdue. Record review of CR #1's January 2025 billing invoice dated 01/06/2025 to 01/31/2025 reflected the CR had been invoiced for a 26-day stay at the nursing facility (NF). Record review of CR #1's February 2025 billing invoice dated 02/01/2025 to 02/03/2025 reflected the CR had been invoiced for a 2-day stay at the NF. Record review of CR #2's Facesheet dated 03/20/2025 revealed CR #2 was an 86-years old female who originally admitted to the NF on 12/24/2024 and discharged on 01/09/2025. CR #2's diagnosis included but were not limited to hypertension (common condition where the force of blood against the artery walls is consistently too high) hyperlipidemia (a condition where there are elevated levels of fats (lipids) in the blood), osteoarthritis (breakdown of cartilage and the underlying bone causing pain, stiffness, and basal cell carcinoma of skin (cancer caused by sun exposure). Record review on 05/14/2025 at 10:38 a.m. revealed that CR #2's MDS discharge ARD had been due on 01/09/2025 and had been 111-days overdue. Record review of CR #2's December 2024 billing invoice dated 12/24/2024 to 12/31/2024 reflected the CR had been invoiced for an 8-day stay at the NF. Record review of CR #2's January 2025 billing invoice dated 01/01/2025 to 01/09/2025 reflected the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 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 0640 CR had been invoiced for a 8-day stay at the NF. Level of Harm - Minimal harm or potential for actual harm Record review of CR #3's Facesheet dated 03/20/2025 revealed CR #3 was a 79-years old female who originally admitted to the NF on 12/31/2024 and discharged on 01/13/2025. CR #3's diagnosis included but were not limited to specified fracture of left pubis (a break in the pubic bone on the left side of the pelvis). Residents Affected - Some Record review on 05/14/2025 at 10:37 a.m. revealed that CR #3's MDS discharge ARD had been due on 01/13/2025 and had been 107 days overdue. Record review of CR #3's December 2024 billing invoice dated 12/31/2024 to 12/31/2024 reflected the CR had been invoiced for an 1-day stay at the NF. Record review of CR #3's January 2025 billing invoice dated 01/01/2025 to 01/13/2025 reflected the CR had been invoiced for a 12-day stay at the NF. During an interview on 05/15/2025 at 01:41 p.m., MDS Coordinator stated CR#1, CR#2, and CR #3's MDS assessments had not been transmitted and it had been her responsibility to upload them timely. She stated she had safeguard mechanisms in place to assist with uploading timely such as a MDS schedule, and discussions during morning manager meetings, but due to the NF's high resident turnover the assessments had been missed. She stated that the negative outcomes of not uploading the assessments timely could result in assessments being left open, not correctly reflecting a resident's discharge outcome to the community, and cause discrepancy with the business offices billing functions. During an interview on 05/15/2025 at 02:14 p.m., the Business Office Manager (BOM) stated that she had not been aware that CR#1, CR#2, and CR #3's MDS assessments were not completed. She stated it had been MDS Coordinator's responsibility to complete the assessments. She stated that the completion of the MDS assessments determined the days needed to bill a resident's insurance company. She stated failure to complete the assessments timely could result in incorrect billing. She stated she was unaware if there were any billing issues as a result of the late assessments. During an interview on 05/15/2025 at 02:39 p.m., LVN D stated that she had been responsible for creating a discharge log to alert when and which residents were scheduled for discharge. She stated when a resident was scheduled for discharge, she sent an email to management to include the MDS Coordinator. She stated once MDS Coordinator received the email she was to have begun the MDS discharge process/assessments. She stated that MDS Coordinated was alerted by way of email that of CR#1, CR#2, and CR #3's discharges from the NF and MDS Coordinated confirmed receipt of the emails relating to the CR's discharges. During an interview on 05/15/2025 at 02:54 p.m., the Director of Nursing (DON) stated it had been her expectation that MDS assessments were completed timely and followed through based on the company's protocols. She stated that the negative outcomes of not completing the MDS assessments timely could result in an incorrect calculation of days within the NF for billing purposes. During an interview on 05/15/2025 at 03:10 p.m. the Administrator stated that she was not aware of CR#1, CR#2, and CR #3's incomplete MDS Assessments. She stated that discharges were discussed in every morning meeting, and they were presented a roster of discharged residents. She stated that she was not aware how a resident discharged could have been missed. She stated it had been her expectations that MDS assessments were completed in a timely manner. She stated that the negative outcomes of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 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 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some not completing the MDS assessments timely could result in an incorrect calculation of days within the NF for billing purposes. Record review of NF policy dated Date Implemented: February 2017 Date Revised: September 2022 and titled Admission, Transfer, and Discharge Compliance Guidelines: A physician extender may complete documentation of the transfer/discharge unless prohibited by state law or community policy. Preparation and orientation for discharge or transfer. Preparation and orientation are essential to ensure safe and orderly transfer or discharge from the community. Sufficient preparation means that the community informs the resident where he or she is going and takes steps under its control to ensure safe transportation. In addition, the community involves the resident and the resident's family in selecting the new residence. Medicaid Residents: In the case of a person eligible for Medicaid, a nursing community must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State Plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission, or continued stay in the community. However, a nursing community may: 1. charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State Plan as included in the term nursing community services: so long as the community gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of these additional services; and 2. solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid-eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the community for a Medicaid-eligible resident. Discharge Planning: Discharge planning begins prior to the resident's admission and continues throughout the resident's stay. The purpose of discharge planning is to identify the resident's specific needs after discharge, such as personal care, sterile dressings, and physical therapy, and describes resident/caregiver education needs and the ability to meet care needs after discharge. Discharge planning will also help the community determine whether the resident can go to al ess restrictive environment, such as assisted living, home, residential community, group home, or another community-based situation. The community will utilize a multidisciplinary approach involving the communities' team members, the resident and responsible party, family members, friends, post discharge caregivers, and support persons who will help the residents adjust to his or her new living environment. Record review of NF policy dated Date Implemented: February 2017 Date Revised: January 2023 and titled Care Plans reflected: The community develops a comprehensive care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan should be reflective of the identified problem or risk, a measurable outcome objective and appropriate intervention/interventions in relation to the identified problem or risk, outcome objective, and the resident's ability, needs, medical condition, preventative measures. The care plan may also include the expressed preferences. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 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 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some care plan in conjunction with the plan of care throughout the medical record is developed and or recommended to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Interdisciplinary means that professional disciplines work together to provide the greatest benefit to the resident. The Interdisciplinary Determination Team (IDT) should include within the care plan the right to refuse any recommended care, treatment or services identified but, that is not provided due to the resident exercising his or her right to refuse care, service, or treatment, as well as the resident's legal representative acting on behalf of the resident. ? The goal or outcome objection should be measurable; however, not every goal or outcome objective must have an interdisciplinary approach. ? The care plan should be initiated upon admission, continued to be developed during the initial 48-72 hrs., throughout the completion of the admission comprehensive assessment. The care plan should be updated and reviewed at least quarterly thereafter, then annually and with significant changes in conditions as defined in the Resident Assessment Instrument (RAI) manual. Additional updates to the care plan may be done as indicated. ? The care plan should be developed no later than seven days following the completion of the comprehensive assessment. ? The care plan should be prepared, reviewed and updated in accordance with the RAI guidance on a routine cadence (admission, quarterly, annually and with significant change). Additionally, the care plan should be modified as appropriate and on an as needed basis as per the RAI instructions. The care plan should be reflective of the resident's/representative's input, goals, and desired outcomes and should include the interdisciplinary team, to include but not limited to the attending physician, a registered nurse with responsibility for the resident, and other appropriate team members in disciplines as determined by the resident's needs. ? The care plan development should involve participation of the resident and his or her family or legal representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 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 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. Based on observation, interviews, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one (Medication Aide Cart South Station 500 (Medication Cart #1)) of five medication carts observed for storage of medications. The facility failed to ensure the Medication Cart #1 was secured when unattended. This deficient practice could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Observation on 05/14/2025 at 7:35 am revealed Medication Cart #1 observed unlocked and no person near cart in the 500-hall nursing station area. Interview and observation with LVN A on 05/14/2025 at 7:35 am, LVN A was notified Medication Cart #1 was unlocked, she pressed the lock. LVN A stated the medication cart should be locked when not attended, so people could not get in it, to prevent theft of medication, to prevent residents from getting medications that are not ordered for them and prevent adverse effects. Interview and observation with MA B on 05/14/2025 at 7:55 am when MA B was notified Medication Cart #1 was unlocked. MA B stated she has not been near the cart on 05/14/2025 and was unaware it was unlocked. MA B stated medication cart should be locked when not in use for the safety of residents. Interview with the Director of Nursing (DON) on 05/14/2025 at 2:00 PM, DON stated all medication carts should be locked when not in use. The risk of the medication cart not being locked was anyone can get into the cart and take something out they should not have. DON reported her plan of correction would be in-service and re-educate the staff and perform rounds several times daily to assure medication carts are locked when not in use. Interview with the Assistant Director of Nursing (ADON) on 05/15/2025 at 9:05 AM, ADON stated all medication carts should be locked when not in use. She stated the risk of the medication cart not being locked was anyone can get into the cart and take something out they should not have. ADON reported she would monitor all carts several times daily when rounding. Interview with the Administrator on 05/15/2025 at 2:45 pm, Administrator stated all medication carts should be locked when not in use. She reported the med cart should be locked by pushing the lock button in when not attended and the keys are held by the person assigned to that cart for the day. She stated the reason the cart should be locked was to keep medications secure, prevent drug diversion, resident safety, prevent resident illness, injury, or death. She reported education regarding locking medication carts is given in orientation, as needed and annually. Administrator reported she would monitor all carts several times daily when rounding. Record review of the facility's policy: Medication Cart Use & Storage Revised 2023. Compliance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 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 Guidelines: The nursing Team Members (Nurses & CMA's) use the medication cart to systematically distribute physician ordered medications to residents. RESPONSIBLE DISCIPLINES Licensed nurses, C.M.A.'s GUIDELINES 1. Security o The medication cart and its storage bins should be kept closed, secured and/or in the line of sight when not in use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure the ice machine was free from items (wet towel) within the stored ice. These failures could place residents at risk for food borne illness. The findings included: In an observation on 05/13/2025 at 8:31 a.m., during the Nursing Facility (NF)'s initial kitchen tour of 1 of 1 ice machines laid a moist white towel a crossed the opening of the machine where the machine's door rested closed. Upon opening of the ice machine door, the towel was observed resting just at atop of the ice near the opening of the machine. Upon the DM's observation of the towel, the DM immediately removed the towel and on the side that the towel that rested inside the machine, ice was observed stuck to the bottom of the towel. When the towel was quickly removed by the DM, some ice pieces flew off the bottom of the towel a crossed the room from the force of the DM's removal from the machine. In an interview on 05/13/2025 at 08:32 a.m., the DM stated that the white towel had been laid on the opening of the ice machine to capture moisture that accumulated in that area. She stated she was unaware who placed the towel there, but it should not have been there as it was an infection control issue. In an interview on 05/14/2025 at 03:26 p.m., the DM stated that the maintenance director empty, cleaned, and sanitized the ice machine after the towel was observed within. She stated a sign was placed on the machine while it was with going cleaning and the staff were in-service and educated to not leave towels or anything resting inside the ice machine. She stated leaving a wet towel within the ice machine left the ice susceptible to cross contamination and with the facility's high-risk residents, left the residents at risk of contact with bacteria because that ice would then be dirty. She stated she was not sure who was responsible for the placement of the towel, but the kitchen staff were educated to just wipe down the ice machine as condensation as it accumulated and remove the towel from the area. In an interview on 05/14/2025 at 3:54 p.m., the DON stated that the kitchen staff were in serviced on the hazards of infection control issues relating to the wet towel resting within the ice machine. She stated that residents were at risk of infections from whatever could have been on the towel that rested against the ice in the ice machine and would not have been favorable ice to consume. In an interview on 05/15/2025 at 3:10 p.m., the Administrator stated that the ice machine had been cleaned and placed out of service by the maintenance department on 04/24/2025 and on 05/13/2025 after the towel was discovered resting within. She stated that on 04/24/2025 she nor the maintenance department or the dietitian observed a towel on the ice machine and had they, they would have immediately removed the towel, and in-service staff on the infection control and infection issues having a towel resting on ice could place resident at risk of. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Record review of policy undated and Policy: Ice Machines. Policy. The facility will maintain the ice machine:, scoop and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once each day. Residents Affected - Some Procedure: l. Unplug ice machine and remove ice. 2. Wash interior with detergent solution. 3. Rinse and drain with hot water. 4. Sanitize and air dry. 5. Clean the exterior with detergent solution and rinse. 6. Clean underneath and around the machine. 7. Wash and sanitize the ice scoop at least once each day in the dishwasher and air dry. 8. Store the ice scoop in a clean non-porous container that allows water to drain off. 9. Use the scoop to serve ice. Place only in clean containers or glasses. 10. Use fresh ice only. Do not reuse ice. Record review of in-service training dated 05/13/2025 and titled Training/Retraining. Topic: Proper handling of ice machine. Ice machine will maintain free of leaks and free of risk of contamination (example: no towels). Signed by DM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpster reviewed for food and nutrition services. Residents Affected - Some 1. The facility failed to ensure doors were closed on 2 of 2 dumpsters and 1 of the 2 dumpsters had exposed bagged trash at the door's opening. This failure could place residents at risk of contact with pests and associated diseases Findings include: In an observation on 05/13/2025 at 8:20 a.m., during the Nursing Facility (NF)'s initial kitchen tour of 2 of 2 dumpsters located outside the NF, the doors were opened on both of the 2-dumpsters and 1-dumpster had exposed bagged trash at the door's opening. On both dumpster doors were signs attached that read in part Keep trash closed at all times. The Dietary Manager (DM) closed both dumpster doors immediately upon observation. During an interview on 05/13/2025 at 8:21 a.m., the DM stated that the dumpster doors were to always remain closed to maintain pest control. She stated it had been the responsibility of all that NF staff that used the dumpster to keep the doors closed. During an interview on 05/14/2025 at 03:26 p.m., the DM stated that all the department staff disposed of trash in the dumpster. She stated the importance of keeping the dumpster doors closed after use was to ensure that rodents were kept out and to maintain pest control. She stated the maintenance director's had the responsibility to initiate pest control in-services for the NF. During an interview on 05/15/2025 at 3:10 p.m., the Administrator stated that dumpster doors were to always remain closed to ensure that racoons and other critters could not get within and cause pest control issues. She stated that the NF staff received an in-service on the importance of the dumpster doors remaining closed after it was discovered during the initial kitchen tour that the door were found opened. During an interview on 05/15/2025 at 03:54 p.m., the Director of Nursing (DON) stated that it was everyone who disposed of trash in the NF dumpster to ensure the dumpster doors were closed and to conceal trash within and keep ensuring that nothing and no one got within. She stated that there were no risks to the residents if the doors had not remained closed as the residents did not dwell near the dumpsters. She stated any infestation that could occur due to failure to keep the dumpster doors closed would not affect the residents because the dumpsters were far enough away for the NF. She stated that in-services were performed all the time on proper trash disposal to include keeping the dumpster doors closed. She stated that the NF staff received an in-service on the importance of the dumpster doors remaining closed after it was discovered during the initial kitchen tour that the door were found opened. Record review on 05/13/2025 at 12:28 p.m., reflected an in-service training dated 8/16/2024 and titled Training/Retraining . After disposal of trash, please make sure trash containers are closed after every use and that all exterior doors are closed. Signed by the DM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Records request on 05/13/2025 at 08:54 a.m., for a policy on trash disposal had been asked and not received. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 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 failed to ensure an infection prevention and control program designed to provide a safe, and sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #195) reviewed for infection control. Residents Affected - Few The facility failed to ensure intravenous tubing was stored safely with medication attached, dated, timed, initialed, and free of contamination while hanging on pole. This failure could place residents at risk of infection, worsening infection, and a decreased quality of life. Findings include: Findings included: Record review of Resident #195's, face sheet dated May 13, 2025, indicated that resident was a 52-yearold male who was initially admitted to the facility on [DATE]. Resident #195 had diagnoses which included Sepsis (is a life-threatening medical emergency caused by your body's overwhelming response to an infection), Acute Appendicitis (is a sudden and severe inflammation of the appendix). Record review of the Minimum Data Set (MDS) assessment, dated 04/19/2025, indicated that Resident #195 had moderately impaired cognition. The MDS indicated that Resident #195 needed setup or on person supervision for transferring, eating, toileting, bathing, and locomotion. Record review of the comprehensive care plan, created 04/17/2025, indicated that Resident #195 Focus: at risk for infection or recurrent/chronic infection related to compromised medical condition. Goal: will be free from signs and symptoms of infections and any complications related to infection through the review date. Interventions: Report changes in condition to MD as clinically indicated. Enhanced Barrier Precautions practices as clinically indicated. Record review of the Medication Administration Report (MAR) dated 05/01/2025-05/31/2025, indicated Resident #195 had an order for Meropenem Solution Reconstituted 1 GM to be given three times daily intravenously for infection, Mycomine Intravenous Solution Reconstituted 100 mg to be given one time daily intravenously for infection, flush with Normal Saline Flush solution before and after medications. Observation and interview on 05/13/2025 at 10:14 am with R#195 revealed used Intravenous (IV) tubing hanging from IV pole. There was no medication attached to IV tubing, no cap at the end of the line. The tubing was not dated, timed, or initialed. Resident stated he did not know why the IV tubing was hanging there like that. Observation and interview on 05/13/2025 at 10:15 am with LVN C revealed she was unaware that the IV tubing was hanging on the pole without medication or cap attached, not labeled, dated, or initialed. LVN C stated it was a potential for infection if the tubing were to be reused. Interview on 5/13/25 at 1:55 PM with the DON , revealed the process for IV infusion was to label, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights on Valley Ranch 23200 Valley Ranch Parkway Porter, TX 77365 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 date and initial IV medication bag or bottle and tubing, post-infusion care to maintain sterility and patient safety. The expectation that staff should not leave unmarked tubing exposed to air is a crucial infection control measure. The DON stated in-services regarding IV services had been given to nurses during orientation, on an as needed basis, and monthly. TheDON stated her expectation is that staff will not leave unmarked tubing hanging on pole with spike open to air. Residents Affected - Few Interview on 5/15/2025 at 9:05 AM with the ADON, revealed the process for IV infusion is to label, date, and initial IV medication bag or bottle and tubing, post-infusion care to maintain sterility and patient safety. She stated the expectation that staff should not leave unmarked tubing exposed to air is a crucial infection control measure. The ADON stated in-services regarding IV services have been given to nurses during orientation, on an as needed basis and monthly. The ADON expectation is that staff will not leave unmarked tubing hanging on pole with spike open to air. Interview on 5/15/2025 at 2:35 pm with the Administrator, revealed her expectation will be strict adherence to policy and procedure for IV medication administration to ensure resident safety. She stated Monitor staff compliance, provide ongoing education, and conduct observations to maintain high standards of care . Record review of -IV Policies and Procedures Manual_v3.0. indicated, Page 11 4.3.3 Dial-A-Flow Instruction for Infusion Set-Up 15. Remove the end of the medication tubing from the PIC line, making sure not to contaminate the end of the tubing, and place a red cap to cover and protect until next use. 16. Leave the IV bag attached to the tubing until the next dose is due.4.6.21 Setting Up page 22 Procedure 1. After verifying the label on IV bag matches with the prescribed order, attach the label to the tubing and bag with the date, time, and nurse's initials. 10. When the therapy is complete, disconnect from the resident's catheter and cap the tubing, and flush per facility procedure if administering medication. Record Review of IFC Infection Prevention and Control 4 2024v2 Infection Prevention and Control, revised April 2024 indicated, Compliance Guidelines: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Prevention of Infection a. Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; (5) educating staff and ensuring that they adhere to reporting exposures to potentially infectious materials; (6) educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his/her role responsibilities and situation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676476 If continuation sheet Page 14 of 14