The Suites Pasadena

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and comfort, prevent infection to the extent possible ' and to prevent and assess for skin breakdown.

Provide privacy by pulling privacy curtain or closing room door if a private room.Record review of the facility's policy on Promoting/Maintaining Resident Dignity, undated, read in part: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Maintain resident privacy. Random

observations and/or verifications are conducted by the Director of Nursing Services (DNS), or designee, to ensure compliance with this policy.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Suites Pasadena

4900 East Sam Houston Parkway South Pasadena, TX 77505

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

10:50am, LVN G said she was the Wound Care Nurse. She said the weekly skin assessment should still be performed by the floor nurse, even if they had wounds. She said she filled out the Weekly Wound Review and it was based off the measurements the Wound Care MD gave her.In an interview on 8/12/25 at 11:41am, the ADM said a skin assessment was performed at every admission and was documented under

the Admission/Baseline Care Plan. She said then weekly, a head-to-toe skin assessment was performed by one of the 3 different shifts, according to the schedule at the nursing station. The ADM said the Weekly Wound Review should be done along with the Weekly Skin assessment. The ADM said the nurses were trained on performing skin assessments and knew the schedule on when to perform them. She said she did not know why the nurses were not doing the skin assessments and had not heard anything from them about the assessments not being done.In an interview on 8/12/25 at 3:15pm, the ADM said she investigated the reason for the skin assessments not being done and Resident #2's weekly skin assessments were never triggered in the EMR. She said she would call the company to see what was going on. The ADM said even though it did not trigger in the system, the nurses should have known to do

the assessment, even if they had to do it on paper.In an interview on 8/12/25 at 4:47pm, the ADM said after investigation of the other resident's skin assessments not being done, she thinks they were overlooked. She said the ADON normally would follow up on skin assessments to ensure they got done and she had not had an ADON in a few weeks. She said she also was in between DONs so everyone was stretched thin.

She said if skin assessments were not done, they could miss skin issues and residents could get wounds.Record review of the facility's policy and procedure on Skin Assessment, undated, read in part: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management.A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury.Document if resident refused assessment and why.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Suites Pasadena

4900 East Sam Houston Parkway South Pasadena, TX 77505

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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

they needed to give the sheets to the nurse and then the nurse gave them to the Treatment Nurse.Record reviews performed by the Surveyor on 8/23/25:- Braden Scales (determines risk for skin breakdown) for all residents were completed on 8/21/25 and revealed 17 at risk, 4 at moderate risk, 2 at high risk, and 12 with no risk.- A list of residents whose Kardex and Care Plan had been reviewed by the DON on 8/21/25.In-services given by the DON on 8/21/25 to the CNAs and Licensed Nurses on Early Identification of PUs with 24 staff signatures.- In-services given by the DON on 8/21/25 top the Nursing Staff on PU Prevention, Skin Audits, and ANE with 23 signatures.- In-services given by the DON on 8/21/25 to the Treatment Nurse, RNs, and LVNs on PU Prevention with 20 signatures.- Ad Hoc QAPI Meeting from 8/21/25-8/22/25 revealed MD M, the Medical Director, the ADM, the SW, the BOM, the HR Director, the Maintenance Director, the AD, the DM, and the Admissions Director were in attendance.- A sheet that said Admissions on the top and had a column starred that said, Skin Issues: Identified on Admission, Assessment with Notification and New Order for Treatment as Applicable. There was another column starred that said, If Skin Issue Identified, Accuracy of Classification/Stage of Wound Confirmed. The log did not have anyone on it yet.- The Skin Assessment Audits log had 3 residents that had been audited on 8/22/25 and were found to have preventative measures in place, the skin assessment was complete and accurate, and no corrective actions needed to be taken.- The Wound Care Nurse Admission/readmission Audits log was blank and did not have anyone on it yet. An Immediate Jeopardy (IJ) was identified on 8/22/2025. The IJ template was provided to

the facility on 8/22/2025 at 12:55pm. While the IJ was removed on 8/23/2025 at 4:00pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

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If continuation sheet