Health inspection·June 27, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #39's February 2025 MAR indicated Resident #39's Norco was not administered 2/4/25-2/27/25. However, on 2/1/25-1 tablet, 2/2/25-2 tablets, 2/3/25-1 tablet, and 2/28/25- 1 tablet was administered. Record review of Resident #39's March 2025 MAR indicated Resident #39's Norco was not administered 3/1/25-3/12/25, 3/14/25-3/19/25, 3/21/25-3/24/25, and 3/26/25- 3/30/25. However, on 3/13/25-1 tablet, 3/20/25-1 tablet, 3/25/25-1 tablet, and 3/31/25-1 tablet were administered. Record review of Resident #39's narcotic reconciliation log for Norco indicated 81 doses were administered on 2/10/25, 2/12/25- 2/27/25, 3/1/25-3/2/25, 3/6/25-3/7/25, 3/11/25, 3/17/25- 3/21/25, 3/24/25- 3/27/25 and 3/31/25. Interview on 6/26/25 at 12:33 pm. with the DON, she said RN B texted her because she saw her name was on the narcotic count sheet for Resident #44's oxycodone on 3/31/25. RN B said she had not administered oxycodone. The DON said when she conducted her investigation, she focused on residents in the 200 hall, which were long term residents. She said she pick some residents from the 300 hall, which were short-term. She said RN A worked both halls. The DON said she chose residents who were alert and went back a couple of months on the narcotic count sheets. She said she noticed a few counts were off here and there and then ramped up for the month of March. Interview on 6/27/25 at 3:03 p.m. with the DON and Administrator. The DON said she was not aware of any issues with controlled substances other than the incident with RN A that was self-reported. The DON said she was not aware of the missing 56 tablets of hydrocodone for Resident #39 for the month of February. The Administrator and DON said the facility had addressed the issues of controlled substances by giving in-services to staff and daily clinical reviews of the narcotic count sheets. The DON said the expectation for nurses when administering narcotics was, they should sign the narcotic out, indicate pain level, and document on the MAR. The DON said if nurses see that the narcotic count was off, they should notify her. The DON said to prevent future issues with narcotic counts the facility will continue to monitor. The DON said the risk to the resident when a narcotic was not documented on the MAR would be minimal risk because the nurses check the narcotic count sheet before administering the medication. The DON said the risk to the resident when a pain medication was not given to the resident would be the resident could have pain and the doctor would have to be notified. Record review of facility document titled Investigation Best Practices, not dated read in part . 4. Determine 'when' the incident occurred (time or time frame). 9. Complete a comprehensive record review, which may include . Medication Administration Records . Record review of the Abuse and Neglect policy dated April 2007 read in part . 4. The physician and staff will help identify risk factors for abuse within the facility . for example, problems related to staff knowledge, skill, or performance that might affect how the residents are being cared for . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 2 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 that a resident who enters the facility with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #78) of 19 residents reviewed for catheters, as evidenced by: -Resident #78 did not have a STATLOCK (catheter stabilization device) to secure Foley catheter (flexible tube inserted into bladder to drain urine). This failure placed the residents at risk of their Foley catheters getting dislodged, unwanted pain, trauma, infections, and decreasing their quality of life. Resident # 78 Record review of Resident #78's admission face sheet undated revealed a [AGE] year-old-male admitted to the facility on [DATE]. Resident diagnoses included pressure wound stage IV (damage to skin and underlying tissue related to pressure), paraplegia ( paralysis of the lower half of the body), neuromuscular dysfunction of the bladder (nerves controlling he bladder are damaged leading to difficulties storing and emptying the bladder). Record review of Resident #78's admission MDS dated [DATE] reflected a BIMS score of 15 which indicated the resident's cognition was intact. Further review section H (Bowel bladder) reflected that resident had an indwelling catheter. Record review of Resident #78's Comprehensive Care Plan dated 05/29/2025 reflected: Focus: Resident had a foley catheter related to neurogenic bladder. Goal: Resident would remain catheter trauma free Interventions: check tubing for kinks each shift Record review of Resident #78's Physician Order for 06/01/2025 reflected the following order: -Dated 05/29/2025 Foley catheter size_16Fr and balloon size_10 cc for neurogenic bladder (nerves controlling he bladder are damaged leading to difficulties storing and emptying the bladder).change -Foley catheter care every shift and as needed. Observation and interview on 06/24/2025 at 12:45 PM revealed Resident #78 in bed awake, alert, and oriented. Resident # 78 had a foley drainage bag hanging on the right side of his bed. The observation revealed the catheter tubing was laying over his right leg without a Statlock (catheter stabilization device that secures a catheter in place, helps to minimize catheter movement and accidental removal) to prevent Foley tubing from accidently being dislodged or pulling on the tube. Resident #78 stated he did not have anything currently holding the tubing in place to his leg and he stated he never had anything. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 3 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 In an interview on 06/25/2025 at 3:56 PM the DON stated catheter tubes were to be secured in place with a statlock. The purpose of the statlock was to keep the tube from pulling causing injury to the resident's urethra. The DON stated if a CNA finds a resident without the tube secured, they were to notify the nurse. To prevent this from happening again they can make it standard protocol on the Medication Administration Record/ Treatment Administration Record so it will have to be assessed daily. Residents Affected - Few In an interview with the Administrator on 06/25/2025 at 4:10 PM he stated he knew the tube was to be secured to help minimize the risk of injury from it moving. The Administrator stated it was best practice to secure the tube and they can add it to the MAR. In an interview on 06/26/2025 at 9:20 AM CNA D stated if she saw a resident and the catheter was not secured she would notify the nurse. The CNA stated the purpose of the tube being secured was to keep the tube from pulling. CNA D stated in the past she did see Resident #78 not have his tube secured and she did notify the nurse. In an interview on 06/26/2025 at 9:36 PM LVN E stated if a resident did not have a statlock she would get one. LVN E stated the purpose was to prevent the tube pulling and damage Record review of the facility policy on Catheter Care, Urinary revised April 2010 reflected in part: The purpose of this procedure is to prevent urinary tract infections . 2. Ensure that the catheter remains secured with a securement device such as a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 4 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 9 (Resident #39, Resident #44, Resident #79, CR #1, CR #2, CR #3, CR #4, CR #5, CR #6) of 18 residents reviewed for pharmacy services. The facility failed to ensure the reconciliation of controlled drug sheets compared to MAR for Resident #39, Resident #44, Resident #79, CR #1, CR #2, CR #3, CR #4, CR #5, CR #6 to ensure every controlled drug that was administered and documented as administered in the MAR reflected the correct quantity on the controlled drug/disposition form. These failures could place residents at risk of medication error and drug diversion due to not reconciling every shift nor accounting for all controlled drugs administered and/or wasted. Findings included: Record review of Resident #39's face sheet dated 6/25/25 indicated she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region without neurogenic claudication (a condition where the spinal canal in the lower back narrows), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), spinal stenosis cervical region (a condition where the spinal canal in the neck narrows, compressing the spinal cord and nerves) and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). Record review of Resident #39's most recent quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 13 indicating cognition was intact. Further review of the quarterly MDS assessment indicated Resident #39 received a scheduled pain medication regimen and PRN pain medications in the last five days. Record review of Resident #39's comprehensive care plan dated 8/20/24 indicated she had potential for pain secondary to lumbar and cervical stenosis with interventions that included: administer analgesia as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, and observe/document for side effects of pain medication. Record review of Resident #39's physician orders with a start date 6/29/24, indicated she was prescribed Norco oral tablet 7.5- 325mg, 1 tablet by mouth every 6 hours as needed for moderate pain. Record review of Resident #39's February 2025 MAR indicated Resident #39's Norco was not administered 2/4/25-2/27/25. However, on 2/1/25-1 tablet, 2/2/25-2 tablets, 2/3/25-1 tablet, and 2/28/25- 1 tablet was administered. Record review of Resident #39's March 2025 MAR indicated Resident #39's Norco was not administered 3/1/25-3/12/25, 3/14/25-3/19/25, 3/21/25-3/24/25, and 3/26/25- 3/30/25. However, on 3/13/25-1 tablet, 3/20/25-1 tablet, 3/25/25-1 tablet, and 3/31/25-1 tablet were administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 5 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #39's narcotic reconciliation log for Norco indicated 81 doses were administered on 2/10/25, 2/12/25- 2/27/25, 3/1/25-3/2/25, 3/6/25-3/7/25, 3/11/25, 3/17/25- 3/21/25, 3/24/25- 3/27/25 and 3/31/25. Interview on 6/24/25 at 2:45 pm, Resident #39 remembered she was told RN A was charting medication that was given to her but did not receive it. Resident #39 could not recall if she was in pain around that time because she said she received her pain medication whenever she requested it. Record review of Resident #44's face sheet dated 6/24/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of acute chronic systolic heart failure, respiratory failure, hematemesis (vomiting blood), multiple sites of contracture of muscle, chronic pain, and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #44's most recent quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 10 indicating cognition was moderately impaired. Further review of the quarterly MDS assessment indicated Resident #44 received a scheduled pain medication regimen and PRN pain medications in the last five days. Record review of Resident #44's comprehensive care plan dated 6/26/24 indicated he had risks for potential complications associated with pain r/t chronic pain bilateral lower leg contracture with interventions that included: administer analgesia as per orders, evaluated the effectiveness of pain interventions, and observe for side effects of pain medication. Record review of Resident #44's physician orders with a start date of 2/15/25, indicated he was prescribed oxycodone HCL oral tablet 20mg, 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #44's March 2025 MAR indicated Resident #44's oxycodone was not administered on 3/5/25, 3/12/25, 3/17/25, 3/24/25, and from 3/27/25-3/31/25. However, on 3/1/25-3/4/25-6 tablets, 3/6/25-3/11/25-10 tablets, 3/13/25-3/16/25-7 tablets, 3/18/25-3/23/25-13-tablets, 3/25/25-3/26/25-3 tablets were administered. Record review of Resident #44's narcotic reconciliation log for oxycodone indicated 10 doses were administered from 3/23/25- 3/25/25, 3/26/25-3/27/25, 3/29/25, and 3/31/25. Interview on 6/24/25 at 2:53 pm, with Resident #44, he said he remembered hearing a nurse was signing out for meds, he could not recall which nurse. Resident #44 said he did not have any issues dealing with pain around that time. Resident #44 said his pain medications were PRN, and he knew he was receiving the correct pill because he was able to identify it as a little white pill. Record review of Resident #79's face sheet dated 6/27/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Type 2 diabetes, chronic osteomyelitis (an infection in a bone that can affect one or more parts of a bone), Stage 4 pressure ulcer of right hip, and Stage 4 pressure ulcer of left hip. Record review of Resident #79's most recent quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 15 indicating cognition was intact. Further review of the quarterly MDS assessment indicated Resident #79 did not receive a scheduled pain medication regimen or PRN pain medications in the last five days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 6 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0755 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #79's comprehensive care plan dated 6/5/25 indicated he had not been care planned for pain interventions. Record review of Resident #79's physician orders with a start date of 11/19/24 indicated he was prescribed Tramadol HCL tablet 50 mg every 6 hours as needed for pain. Residents Affected - Some Record review of Resident #79's February 2025 MAR indicated Resident #79's Tramadol was not administered from 2/1/25- 2/2/25, 2/4/25, 2/6/25- 2/10/25, 2/12/25-2/13/25, and from 2/16/25- 2/28/25. However, on 2/3/25-1 tablet, 2/5/25-1 tablet, 2/11/25-1 tablet, 2/14/25-1 tablet, and 2/15/25- 1 tablet was administered. Record review of Resident #79's narcotic reconciliation log for tramadol indicated 3 doses were administered between 2/3/25-2/4/25, and 2/12/25. Interview on 6/26/25 at 4:53 pm, Resident #79 he said he had chronic pain from neuropathy. Back in February, he was told by a couple of nurses he did not have pain medication. When asked if the nurses still worked at the facility he responded, I'd rather not say. Resident #79 said the way he found out he had pain medication was he requested for his medical records. Resident #79 said he has not had any issues receiving his pain meds after he requested his records. Record review of CR #1's face sheet dated 6/26/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region without neurogenic claudication (a condition where the spinal canal in the lower back narrows), polyosteoarthritis (arthritis that affects five or more joints at the same time), stiffness of unspecified joint, osteomyelitis of vertebra (a rare bone infection that inflames and infects a spinal disc), and burn of first degree of right thigh. Record review of CR #1's most recent comprehensive MDS assessment indicated he had a BIMS score of 15 indicating cognition was intact. Further review of the comprehensive MDS assessment indicated CR #1 received a scheduled pain medication regimen and PRN pain medications in the last five days. Record review of CR #1's comprehensive care plan dated 3/15/25 indicated he had not been care planned for pain interventions. Record review of CR #1's physician orders with a start date of 3/21/25 indicated he was prescribed Tramadol HCL oral tablet 50 mg, every 6 hours as needed for pain. Record review of CR #1's March 2025 MAR indicated CR #1's tramadol was not administered from 3/22/25-3/23/25, and 3/30/25. However, on 3/21/25- 1 tablet, 3/24/25-1 tablet, 3/25/25- 1 tablet, 3/26/25-3 tablets, 3/27/25- 1 tablet, 3/28/25- 3 tablets, 3/29/25-3 tablets, and 3/31/25- 3 tablets were administered. Record review of CR #1's narcotic reconciliation log for tramadol indicated 8 doses were administered from 3/22/25-3/23/25, 3/27/25, and from 3/29/25- 3/30/25. Record review of CR #2's face sheet dated 6/26/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of sepsis, Type 2 diabetes, thyrotoxicosis (a rare and life-threatening condition that occurs when the thyroid gland releases a large amount of thyroid hormones in a short period), hyperlipidemia (a condition in which there are high levels of fat particles (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 7 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0755 in the blood). Level of Harm - Minimal harm or potential for actual harm Record review of CR #2's most recent comprehensive MDS assessment dated [DATE] indicated she had a BIMS score 15 indicating cognition was intact. Further review of the comprehensive MDS assessment indicated CR #2 did not receive a scheduled pain medication regimen or PRN pain medications in the last five days. Residents Affected - Some Record review of CR #2's comprehensive care plan dated 3/27/25 indicated she had pain with interventions that included: administer analgesia as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions. Record review of CR #2's physician orders with a start date of 3/26/25 indicated she was prescribed hydrocodone-acetaminophen oral tablet 7.5- 325 mg tablet every 6 hours as needed for pain. Record review of CR #2's March 2025 MAR indicated CR #2's hydrocodone was not administered from 3/26/25-3/27/25 and from 3/29/25-3/30/25. However, on 3/28/25- 1 tablet and 3/31/25- 3 tablets were administered. Record review of CR #2's narcotic reconciliation log for hydrocodone indicated 7 doses were administered between 3/27/25- 3/30/25. Record review of CR #3's face sheet dated 6/26/25 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of secondary malignant neoplasm of liver, malignant neoplasm of colon, Type 2 diabetes, pain in right shoulder. Record review of CR #3's most recent comprehensive MDS assessment dated [DATE] indicated he had a BIMS score 15 indicating cognition was intact. Further review of the comprehensive MDS assessment indicated CR #3 received a pain medication regimen in the last five days. Record review of CR #3's comprehensive care plan dated 2/27/25 indicated he had not been care planned for pain interventions. Record review of CR #3's physician orders with a start date of 3/6/25 indicated he was prescribed tramadol HCL oral tablet 50 mg every eight hours as needed for pain management. Record review of CR #3's March 2025 MAR indicated CR #3's tramadol was not administered on 3/6/25, 3/8/25-3/9/25, and from 3/11/25-3/31/25. However, on 3/7/25-1 tablet, 3/10/25-1 tablet was administered. Record review of CR #3's narcotic reconciliation log for tramadol indicated 5 doses were administered between 3/8/25 thru 3/9/25. Record review of CR #4's face sheet dated 6/26/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction, end stage renal disease, hyperlipidemia. Record review of CR #4's most recent comprehensive MDS assessment dated [DATE] indicated she had a BIMS score 15 indicating cognition was intact. Further review of the comprehensive MDS assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 8 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0755 Level of Harm - Minimal harm or potential for actual harm indicated CR #4 received PRN pain medications and received non-medication intervention for pain in the last five days. Record review of CR #4's comprehensive care plan dated 3/11/25 indicated she had not been care planned for pain interventions. Residents Affected - Some Record review of CR #4's physician orders with a start date of 3/12/25 indicated she was prescribed hydrocodone-acetaminophen oral tablet 5- 325 mg every 6 hours as needed for pain. Record review of CR #4's March 2025 MAR indicated CR #4's hydrocodone was not administered from 3/15/25- 3/22/25, and from 3/24/25- 3/31/25. However, from 3/12/25 thru 3/14/25- 5 tablets, and 3/23/25- 1 tablet was administered. Record review of CR #4's narcotic reconciliation log for hydrocodone indicated 4 doses were administered between 3/22/25 thru 3/23/25. Record review of CR #5's face sheet dated 6/26/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unilateral primary osteoarthritis-right knee, Type 2 diabetes with diabetic neuropathy. Record review of CR #5's most recent comprehensive MDS assessment dated [DATE] indicated she had a BIMS score of 15 indicating cognition was intact. Further review of the comprehensive MDS assessment indicated CR #5 received a scheduled pain medication regimen, received PRN pain medications, and received non-medication intervention for pain in the last five days. Record review of CR #5's comprehensive care plan dated 3/12/25 indicated she had pain r/t osteoarthritis, right artificial knee joint replacement/swelling with interventions that included: administer analgesia as per orders, anticipate the resident's need for pain relief, evaluate the effectiveness of pain interventions. Record review of CR #5's physician orders with a start date of 3/11/25 indicated she was prescribed hydrocodone-acetaminophen oral tablet 10- 325 mg every 6 hours as needed for moderate pain. Record review of CR #5's March MAR indicated CR #5's hydrocodone was not administered on 3/11/25, 3/16/25, 3/19/25-3/20/25, 3/22/25-3/23/25, and from 3/27/25 thru 3/31/25. However, on 3/12/25- 1 tablet, 3/13/25- 1 tablet, 3/14/25, 1 tablet, 3/15/25- 1 tablet, 3/17/25-1 tablet, 3/18/25- 1 tablet, 3/21/25- 1 tablet, 3/24/25- 1 tablet, 3/25/25- 2 tablets, and 3/26/25- 1 tablet was administered. Record review of CR #5's narcotic reconciliation log for hydrocodone indicated 2 doses were administered on 3/17/25 and 3/28/25. Record review of CR #6's face sheet dated 6/26/25 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cellulitis of right lower limb, acute kidney failure, Type 2 diabetes. Record review of CR #6's most recent comprehensive MDS assessment dated [DATE] indicated she had a BIMS score of 10 indicated cognition was moderately impaired. Further review of the comprehensive MDS assessment indicated CR #6 did not receive a scheduled pain medication regimen or PRN pain medications in the last five days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 9 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of CR #6's comprehensive care plan dated 4/14/25 indicated she had potential for pain r/t diabetes mellitus, CHF, history of recurrent falls, and osteoarthritis with interventions that included: administer pain meds as ordered, evaluate the effectiveness of pain interventions, observe/document for side effects of pain medication. Record review of CR #6's physician orders with a start date of 11/6/24 indicated she was prescribed tramadol HCL oral tablet 50 mg every 6 hours as needed for pain management. Record review of CR #6's February 2025 MAR indicated CR #6's tramadol was not administered from 2/1/25- 2/2/25, 2/5/25-2/8/25, and from 2/10/25-2/28/25. However, on 2/3/25-1 tablet, 2/4/25- 1 tablet, and 2/9/25- 1 tablet was administered. Record review of CR #6's March 2025 MAR indicated CR #6's tramadol was not administered from 3/1/25-3/6/25, 3/8/25, 3/11/25, 3/15/25- 3/26/25, and from 3/28/25- 3/31/25. However, on 3/7/25- 1 tablet, 3/9/25- 1 tablet, 3/10/25- 1 tablet, 3/12/25- 1 tablet, 3/13/25- 1 tablet, 3/14/25- 1 tablet, and 3/27/25- 1 tablet was administered. Record review of CR #6's narcotic reconciliation log for tramadol indicated 3 doses were administered on 2/14/25, and from 3/10/25 thru 3/11/25. Interview on 6/25/25 at 3:03 p.m. with the Nurse Practitioner for pain management. She said she was not aware of narcotics missing. The NP said Resident #39 was prescribed Norco for spinal stenosis and chronic knee pain. The NP said for Resident #44, he was prescribed Oxycodone for pain in his back, hips, and knees. The NP said there was not an increase for pain medication for Resident #39 and Resident #44 for the month of March. She said residents were at risk for increased pain if pain medications were not administered. The NP said when medications are not documented on the MAR, residents were at risk of oversedation if they got too many pain meds. Interview on 6/25/25 at 10:21 a.m. with RN A, she said the DON called her and spoke to her about PRN medications and signing out for other nurses. RN A said she would do the counts at the beginning of her shift with the morning nurse, RN C, and do counts at the end of her shift with different night nurses. She said RN B was the night nurse that was there most of the time. RN A said she worked 200 hall and sometimes cover the 300 hall. RN A said sometimes the narcotic count would not match because staff would forget to sign off on the narcotic sheet. RN A said the DON would have her and other nurses go back and sign the narcotic sheet as far back as a week. RN A said the DON suspended her on 4/1/25 for failing to follow facility policy when administering narcotics and changing times and dates of narcotics given. RN A never returned to the facility because she said she did not agree with what the DON accused her of, it was her word against the DON. Interview with RN B on 6/25/25 at 12:13 p.m. She said she was the night nurse and worked from 10 p.m. to 6 a.m. RN B said she noticed her name was forged on the count sheet on 4/1/25 at 12:00 a.m. RN B said she counted the medications with the evening nurse, she was not sure if it was RN A. RN B said she notified the ADON and DON as soon as she noticed her signature was forged. RN B said when she administered pain medication she always signed in the system and signed on the narcotic sheet. She said documented PRN medications and pain scale for the residents. RN B said the narcotic count sheet and MAR should match. She said the risk to the resident if they did not get their pain meds was the resident would still be in pain. RN B said the DON would need to be notified if there was a discrepancy between the narcotic count sheet and MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 10 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 6/25/25 at 12:45 p.m. with RN C, she said RN A signed out narcotics under her name a few times, she said it was mostly under a night shift nurse's name. RN C said she signed out medications as soon as it was administered. For instance, if she gave a narcotic at 11:06 pm she would sign for it at 11:06 pm. RN C said she had to go back and sign the narcotic sheet because she would get busy. She said sometimes she would have to go back a day or so to sign the narcotic sheet. RN C said the narcotic count sheet should match the MAR. She said the nurses counted narcotics at the beginning and end of shift. RN C said she did not see any discrepancies for the month of March. RN C said the risk to the resident when they did not receive their medication would be their pain would be harder to control. She said the risk to the resident when the narcotic count sheet is signed but not documented on the MAR would be overdose. Interview on 6/26/25 at 12:33 pm. with the DON, she said RN B texted her because she saw her name was on the narcotic count sheet for Resident #44's oxycodone on 3/31/25. RN B said she had not administered oxycodone. The DON said when she conducted her investigation, she focused on residents in the 200 hall, which were long term residents. She said she pick some residents from the 300 hall, which were short-term. She said RN A worked both halls. The DON said she chose residents who were alert and went back a couple of months on the narcotic count sheets. She said she noticed a few counts were off here and there and then ramped up for the month of March. Interview on 6/27/25 at 3:03 p.m. with the DON and Administrator. The DON said she was not aware of any issues with controlled substances other than the incident with RN A that was self-reported. The DON said she was not aware of the missing 56 tablets of hydrocodone for Resident #39 for the month of February. The Administrator and DON said the facility had addressed the issues of controlled substances by giving in-services to staff and daily clinical reviews of the narcotic count sheets. The DON said the expectation for nurses when administering narcotics was, they should sign the narcotic out, indicate pain level, and document on the MAR. The DON said if nurses see that the narcotic count was off, they should notify her. The DON said to prevent future issues with narcotic counts the facility will continue to monitor. The DON said the risk to the resident when a narcotic was not documented on the MAR would be minimal risk because the nurses check the narcotic count sheet before administering the medication. The DON said the risk to the resident when a pain medication was not given to the resident would be the resident could have pain and the doctor would have to be notified. Record review of the Controlled Substances policy dated 12/2012 read in part . 9. Nursing staff must count controlled medications at the end of each shift . the nurse coming on duty and the nurse going off duty must make the count together . they must document and report and discrepancies to the Director of Nursing Services . Record review of the Documentation of Medication Administration policy dated 4/2007 read in part . 1. A nurse . shall document all medications administered to each resident's medication administration record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 11 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain medical records in accordance with accepted medical standards and practices and failed to maintain medical records for 2 residents (Resident #69 and Resident #11) that were accurately documented. -LVN B initialed Resident #69's treatments as been completed prior to the treatments being provided. -Resident #69 had bilateral edema that was not being charted correctly. -LVN B changed documentation after being asked about Resident #69's edema. -LVN B initialed Resident #11's treatment as been completed prior to the treatments being provided. These failures placed residents at risk for not receiving care and worsening of skin conditions. Findings included: Resident #69 Record review of the admission Record for Resident #69 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, mild cognitive impairment, anxiety disorder, and abnormal findings of blood chemistry. Observation and interview on 06/24/25 at 10:30 a.m. with Resident #69 revealed she said she had hit her leg on the shower chair, and it never healed. She said it gets blistered, then pops. She said the facility did not cover it. She said her family member had asked for wound care to come, but she has not been seen by wound care. Observation at that time revealed both of her feet were edematous. There was an open area on her left lower leg that had multiple blistered and burst blisters visible. Open bloody areas were visible. The wound was not covered. There was scant bloody drainage visible on the sheet. Record review of a Change in Condition Evaluation for Resident #69, dated 06/23/25, revealed the resident exhibited increased edema to her left lower leg. The Summary section read, in part, .pt left leg +2 edema and right leg +1 edema There is increased weeping in left leg. The Evaluation was signed by LVN B. Record review on 06/24/25 at 10:48 a.m. of the June 2025 TAR for Resident #69 revealed the treatment Apply barrier cream to bilateral lower extremities qd one time a day for Skin Integrity. Had been initialed as completed by LVN B. LVN B had also documented Resident #69 had zero edema on 06/23/25 and in the morning of 06/24/25. In an interview on 06/24/25 at 10:52 a.m. with LVN B, revealed she said Resident #69 had edema. LVN B said she had addressed it with the doctor yesterday. She said Resident #69 was receiving wound care. LVN B said the wound care Resident #69 was receiving was a barrier cream. LVN B said she had not applied the barrier cream yet today. When asked if the initials on the TAR indicating the 06/24/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 12 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treatment had already been completed were hers, she acknowledged they were. LVN B pulled up Resident #69's TAR on the computer and again said she had not completed the treatment yet. The TAR had her initials in the box for 06/24/25 indicating the treatment had been done. She said she was supposed to sign the TAR after the treatment was completed. In an interview on 06/24/25 at 4:32 p.m., the DON said Resident #69's legs have been like that since November. She said Resident #69's edema was probably 3 to 4. In an interview on 06/24/25 at 4:40 p.m., LVN C, (the facility Infection Control Nurse) said Resident #69 usually had edema. She assessed Resident #69's edema and said Top of left foot pitted. Slow rebound. Left is greater than right. Pitting in both. In an interview on 06/24/25 at 4:45 p.m. LVN B said Yes, I saw her [Resident #69]. She has edema every day. That doesn't happen overnight. I always chart in the morning. She said she would change her entry in the TAR. Record review on 06/25/25 at 11:19 a.m. of the June 2025 TAR for Resident #69 revealed the resident's edema documentation for 06/24/25 morning assessment was changed from 0 to 3+. The edema for the mid-day assessment had been changed from 0 to 2+. Resident 11 Record review of the admission Assessment for Resident #11 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included contractures of both legs, muscle wasting and atrophy, and muscle weakness. Record review of the Quarterly MDS assessment for Resident #11, dated 05/20/25 revealed she had severely impaired cognition. Record review of the Care Plan for Resident #11 revealed she had very high risk for developing pressure sores. One of the interventions read, in part, .Apply creams as ordered. Record review on 06/24/25 at 11:18 a.m. of the June 2025 TAR for Resident #11 revealed LVN B had initialed she had applied barrier cream to Resident #11's bilateral buttocks and sacral area that morning. In an interview on 06/24/25 at 11:22 a.m. LVN B said she did not apply the barrier cream to Resident #11, even though she signed that she did. She said the CNAs apply it. Observation and interview on 06/24/25 at 11:37 a.m. revealed LVN B was at Resident #11's bedside. She said she had not observed the resident's sacral area yet today. The nurse loosened Resident #11's brief. There was no barrier cream on the resident. When the surveyor informed LVN B she had already initialed the barrier cream had been applied, LVN B said I'm not going to say anything else. In an interview on 06/25/25 at 1:20 p.m., LVN C said the nurse should document after the treatment wasis provided or at that time if she was at the cart. The risk was, that if she got called off to a code or something, the other nurse may not know to do the treatment. In an interview on 06/25/25 at 1:45 p.m., the DON said the nurse should sign/initial the TAR during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 13 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 0842 the activity, and some sign it right before they enter the resident's room. Level of Harm - Minimal harm or potential for actual harm The Survey team requested the policy regarding documentation, no policy was provided by the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 14 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 residents (Resident #69 and Resident #8) of 6 residents reviewed for Infection Control. Residents Affected - Some -LVN B failed to follow proper hand hygiene while providing treatment to Resident #69's wounds on her lower legs. -Resident #69 had an open wound but was not on Enhanced Barrier Precautions. -The facility failed to ensure CNA D followed proper infection control, for Resident # 8 during incontinent care. CNA D failed to clean from front to back when the resident was incontinent of stool. These failures placed residents at risk for cross contamination and the spread of infection. Findings included: Resident #69 Record review of the admission Record for Resident #69 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, mild cognitive impairment, anxiety disorder, and abnormal findings of blood chemistry. Record review of a Change in Condition Evaluation for Resident #69, dated 06/23/25, revealed the resident exhibited increased edema to her left lower leg. The Summary section read, in part, .pt left leg +2 edema and right leg +1 edema There is increased weeping in left leg. The Evaluation was signed by LVN B. Record review of the Weekly Skin Review for Resident #69, dated 06/24/25, revealed her left lower leg had red/pink dry skin patches. The measurements were reflected as 9.5 x 9.0 x 0.2 cm. The right leg had redness surrounding a weeping scabbed wound. The report read, in part, .Res has new weeping wound to LLE, previously pink dry patchy skin. Res had change in condition, 3+ bilateral lower ext edema present. Consulted with wound care specialist _____ [Physician A] on tx plan over the phone, ordered - cleanse with ns/wc pat dry apply vashe gauze apply ABD pad, cover with kerlix dressing qd . Observation and interview on 06/24/25 at 10:30 a.m. with Resident #69 revealed she said she had hit her leg on the shower chair, and it never healed. She said it gets blistered, then pops. She said the facility did not cover it. She said her family member sister had asked for wound care to come, but she has not been seen by wound care. Observation at that time revealed both of her feet were edematous. There was an open area on her left lower leg that had multiple blistered and burst blisters visible. Open bloody areas were visible. The wound was not covered. There was scant bloody drainage visible on the sheet. Observation on 06/24/25 at 10:58 a.m. revealed LVN B provide wound care for Resident #69 . There was no Enhanced Barrier Precautions sign on the door. LVN B placed some barrier cream in a 30 cc cup. She did not wash her hands, and donned gloves. With her gloved hand, LVN B applied barrier cream to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 15 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 Resident #69's wound on her left leg. Observation revealed there was drainage visible on the right leg wound. Without sanitizing her hands, LVN B used the same gloves to apply barrier cream to the open area on the right leg. The surveyor asked LVN B if there was drainage from the right leg wound. LVN B answered, A little. LVN B doffed her gloves and washed her hands. The Surveyor asked LVN B if it was ok to apply the barrier cream to the right leg wound with the same gloves as she used on the left. LVN B responded, No. Cross contamination. In an interview on 06/24/25 at 12:05 p.m., LVN C, (the facility Infection Control Nurse) said Resident #69 should be on Enhanced Barrier Precautions (EBP) if the wound was open. LVN C then observed Resident #69 and said she would place her on EBP. In an interview on 06/25/25 at 1:20 p.m., LVN C said LVN B should have washed her hands and changed gloves after treating Resident #69's left leg, before treating the right leg. She said if the wound on the left leg was infected, it could spread to the wound on the right leg. In an interview on 06/25/25 at 1:45 p.m., the DON said if the wound was open, LVN B should have washed her hands and changed gloves after treating Resident #69's left leg. She said the risk would be the spread of infection. Resident #8 Record review of Resident #8's face sheet undated reflected date of admission was 5/25/2023 and readmitted [DATE]. Resident #8's diagnoses Alzheimer's Disease, Cellulitis (common and potentially serious bacterial infection of the skin) of face, personal history of urinary tract infections, dementia, and anxiety Record review of Resident #8's care plan dated 04/04/2025 revealed:.Focus: Resident #8 had bladder incontinence related to dementia and the inability to hold her urineGoals: Resident's risk for septicemia (serious bloodstream infections) will be minimized/prevented by prompt recognition and treatment of urinary tract infection symptomsInterventions: The resident used disposable briefs change as needed Record review of Resident #8's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score was three indicating severe impairment in cognition. Section H (Bladder and Bowel) reflected resident was frequently incontinent of bowel and bladder. Resident #8 was dependent in staff for toileting hygiene. Observation on 06/25/2025 at 10:08 AM during incontinent care for Resident #8 by CNA D assisted by LVN A and LVN B,. Resident #8 was positioned on her right side. Resident # 8 had a soft stool at her anal area. CNA A wiped from the resident's anal area moving to her front peri area for five separate wipes. In an interview on 06/25/2025 at 10:23 AM CNA D stated she was supposed to wipe away from the uterus. CNA D stated she wiped toward the uterus . CNA D stated the resident did have stool and she wiped her 5 times toward the front. The CNA was in-serviced about 2 weeks ago. She stated she was nervous. CNA D stated the risk to the resident was an infection. In an interview on 06/25/2025 at 10:28AM LVN A stated she witnessed CNA D wipe Resident #8 in the wrong direction. LVN A stated she witnessed the resident had stool and the CNA wiped the stool toward (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 16 of 17 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 675819 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089 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 the front of the resident. LVN A stated the risk was infection. Level of Harm - Minimal harm or potential for actual harm In an interview on 06/25/2025 at 11:32 AM LVN B stated she witnessed the CNA wipe Resident #8 from back to front for 5 wipes. LVN B stated she should have wiped front to back. LVN B stated she saw the resident was incontinent of stool and the CNA wiped from back to front. The risk was infection. Residents Affected - Some In an interview on 06/25/2025 at 1:03 PM LVN C stated she had been the infection control preventionist for five years. LVN C stated the CNAs were in-serviced annually and as needed for incontinent care. LVN C stated proper cleaning for incontinent care was from front to back. The LVN stated if the CNA cleaned back to front that was incorrect technique and the risk was contamination and infection. To prevent this they we would increase in-services on peri care. In an interview on 06/25/2025 at 4:13 PM the Administrator stated he heard the resident was cleaned by wiping in the right direction. He said the risk was infection. They would try to prevent by re-inservicing. 1. Record review of the The facility policy Handwashing/Hand Hygiene (revised August 2015) read, in part, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .h. Before moving from a contaminated body site to a clean body site during resident care; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675819 If continuation sheet Page 17 of 17