Inspection·November 20, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete staff should document in the electronic record that the RP/family was notified. In an interview on [DATE] at 10:20 a.m., the Administrator said it was the DON's responsibility to ensure RP/family notification was completed. It was his expectation, if there was a change of condition, the family should be notified as soon as possible. He stated it was important for the family to know what was going on with the resident. The surveyor made two attempts to call LVN A on [DATE] at 12:05 p.m. The number was not available. The facility had no additional contact numbers. The surveyor attempted to call RN H on [DATE] at 12:10 p.m. There was no answer. The surveyor left a voicemail with contact information. RN H did not respond as of the investigation exit. The surveyor attempted to call Resident #1's RP on [DATE] at 11:28 a.m. and 11:30 a.m. There was no answer. The surveyor left a voicemail with contact information. The RP did not respond as of the investigation exit. During an interview on [DATE] at 11:38 a.m., Family Member F said Resident #1's RP was not notified of his change of condition, the x-ray, or the x-ray results. Record review of the facility's Resident Rights policy dated 2001 (revised [DATE]) indicated .be notified of his or her medical condition and of any changes in his or her condition; . Record review of the facility's Change in a Resident's Condition or Status dated 2001 (revised [DATE]) indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status; . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Event ID: Facility ID: 676484 If continuation sheet Page 2 of 5 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 676484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and other officials including to the State Survey Agency in accordance with State law through established procedures for 2 of 10 residents (Residents #2 and #3) reviewed for reporting allegations of abuse. The facility failed to report an allegation of misappropriation within 24 hours after Resident #2's RP reported Resident #2's wallet with $375.40 was missing on 08/06/25. The facility failed to report an allegation of verbal abuse within 2 hours on 08/11/25 when Resident #3's friend reported DA K called Resident #3 a bitch. These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life.Findings included: Record review of Resident #2's face sheet dated 11/04/25 indicated she was a [AGE] year-old female, admitted on [DATE], and her diagnoses included hypoglycemia (low blood glucose level), diabetes (body doesn't make enough insulin or can't use it properly), depression (persistent feeling of sadness), and anxiety (feeling of uneasiness and worry). Record review of Resident #2's admission MDS assessment dated [DATE] indicated she was able to make herself understood and understood others and had moderate cognitive impairment (BIMS-10). There were no noted behaviors. Record review of Resident #2's care plan dated 08/15/25 indicated she had decided to have a surveillance camera in her room[KS1] . Record review of a grievance form dated 08/06/25, indicated Family Member X [KS2] reported to a charge nurse that Resident #2's wallet with $375.35[KS3] was missing. The wallet and money were in a dresser drawer between clothes upon admission on [DATE]. Family Member X indicated she checked the wallet daily and on 08/06/25, the wallet was no longer in the dresser drawer. The missing wallet and money were reported to the Administrator on 08/06/25. The Administrator noted on 08/11/25 he spoke to Resident #2 regarding the missing money. She stated she wasn't sure how or when her wallet went missing. When asked if she felt safe or worried, she said she was fine and showed no emotional distress. The administrator searched Resident #2's room, closet, and drawers and nothing was found. The administrator and DON interviewed all staff assigned to the area including nursing, housekeeping, laundry, and dietary regarding the missing money for several days. All staff were unaware of the grievance and recalled no concerns/distress from Resident #2. On 08/12/25 the Administrator spoke with Resident #2 again to see if she recalled anything and to make sure she still felt safe. She stated everything was fine and showed no signs of distress. On 8/13/25 the Administrator spoke to Resident #2's responsible party and family member T. The Administrator informed her of the investigation process, lack of findings to date and what potential outcomes may be. She confirmed the initial report that stated the only visitor that Resident #2 had recently was family member R, which happened to be on the same day as the wallet came missing but didn't believe she would have taken it. The Administrator informed her the facility would continue to interview staff regarding the missing money and would also be providing re-education to staff regarding abuse and neglect and theft. The RP was satisfied with our efforts and current outcome. Investigation/search would continue. There was no indication that the allegation of misappropriation was reported to HHSC. Record review of Resident #2's progress note dated 08/20/25, completed by LVN A indicated Resident #2 was discharged on to hospital and did not return to the faiclity. Record review of Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676484 If continuation sheet Page 3 of 5 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 676484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #3's face sheet dated 11/04/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included nonrheumatic aortic valve stenosis (the valve is narrowed and doesn't open fully), cognitive communication deficit (communication challenge), anxiety (feeling of uneasiness and worry), unspecified intellectual disabilities, and persistent mood (affective) disorder (chronic form of depression). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others and was cognitively intact (BIMS-15). There were no noted behaviors. Record review of Resident #3's care plan dated 09/14/25 indicated no focus related to the allegation. Record review of Resident #3's progress not completed by RN M indicated Resident #3 passed away on 10/02/25[KS4] . Record review of a grievance dated 08/11/25 reported to the DON, indicated Resident #3 claimed DA K was rude and called her a bitch. The administrator was notified on 08/11/25. The Administrator noted on 08/18/25 he spoke with Resident #3's [KS5] family member N. Resident #3's family member N stated he wasn't sure exactly what was said while staff member(s) were talking to Resident #3 from across the room from the kitchen door. He said he was aware of Resident #3's request for additional butter or something but he wasn't aware of anyone using the b word nor was he aware of who the staff was including if it was DA K. The Administrator spoke with DA K and he denied the allegation. DA K stated he would never use that type of language. He insisted that he did not approach Resident #3 but merely spoke to her from the kitchen door about getting additional butter. He stated other staff members were speaking as well but doesn't recall anyone using the b word towards her. The Administrator followed up with Resident #3 and discussed his findings regarding DA K and other staff members. The Administrator informed her that DA K stated he would never have done that and was willing to apologize to her if that is what she thought. The Administrator informed Resident #3 that customer service and communication were very important and would be reviewed again with the entire team. Resident #3 was satisfied with the outcome. There was no indication the allegation of verbal abuse was reported to HHSC. During an interview on 11/03/25 at 9:40 a.m., the Administrator said he was the abuse coordinator. He said all allegations of abuse, neglect and misappropriation would be reported to him or the designee immediately. He said the facility was required to report allegations of abuse, neglect, misappropriation within the required timeframe[KS6] to HHSC. During an interview on 11/03/25 at 4:02 p.m., the Administrator said he did not report the allegations of misappropriation or abuse. He said when he followed up on Resident #3's RP and friend, Resident #3 was fine and he based his decision to not report the allegation of verbal abuse on his inquiries. He said he could not prove DA K called Resident #3 a bitch. He said he could not prove who took Resident #2's wallet and money so he did not report the allegation of misappropriation. During an interview on 11/04/25 at 10:30 a.m., the DON said she reported the allegation that DA K called Resident #3 a bitch to the Administrator immediately. She said all allegations of abuse were reportable to HHSC within two hours. During an interview on 11/04/25 at 1:51 p.m., DA K denied calling Resident #3 a bitch. He said he was passing by her table, and she asked for cream cheese, and he told her there was none. He said he did not hear any staff use the b word. Record review of the facility's Abuse, Neglect, and Exploitation Policies and Procedures dated 2001 (revised July 2017) indicated .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676484 If continuation sheet Page 4 of 5 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 676484 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mont Belvieu Rehabilitation & Healthcare Center 14000 Lakes of Champions Blvd Mont Belvieu, TX 77523 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 0609 involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676484 If continuation sheet Page 5 of 5