Inspection·March 17, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with LVN F, on 03/16/2023 at 3:55PM, he stated he set Resident #141's flow rate for tube feeding at 50ml/hr and even wrote 50 cc/hr on the bag. He stated He could not picture himself setting it at 60ml/hr if he knew the order and he often checks the tube feed during his rounds and did not notice the flow rate being set incorrectly. He said he was the main person who set the rates and changed the tubing as needed. He stated the flow rate could have been set incorrectly due to human error but also knew he was not the only person going in that room so he is not sure if other nurses or family members could have tampered with the tube feeding. He stated the implications for not having followed the doctor's orders for resident's tube feeding could have been weight gain, nutrition deficits depending if it was greater or lesser than what was ordered. In an interview with the DON, on 03/16/2023 at 1:35PM, she stated the nurses on the floor were supposed to check to ensure the tube feeding rate was set as what was ordered. She stated the implications in the case of Resident #141 could had been fluid overload from the rate being set too high compared to was what ordered. Record review of the facility's policy on enteral nutrition, dated December 2008, revealed Adequate nutritional support though enteral feeding will be provided to residents as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 2 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 - Few 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 observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (Resident #79) reviewed for pharmacy services. -The facility failed to acquire medication from an appropriate source by receiving Resident #79's HIV medication from a clinic without a prescription. - The facility failed to ensure expired medication was not administered to Resident #79. These failures could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Finding Included: Record review of Resident #79's face sheet dated 03/14/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dehydration and cellulitis (a bacterial skin infection). The diagnosis list did not include HIV. Record review of Resident #79's admission MDS dated [DATE] revealed, use of corrective lenses, intact cognition as indicated by a BIMS score of 15 out of 15, worsening of behaviors, limited assistance with most ADLs and occasionally incontinent of both bladder and bowel. Record review of Resident #79's undated care plan revealed, focus- impaired immunity related to asymptomatic HIV infection status. Record review of Resident #79's Physician's Orders dated Kaletra (Lopinavir and Ritonavir) 200 mg/50mg, a medication used to treat HIV, give 2 tablets at bedtime. Record review of Resident #79's March 2023 MAR revealed, Kaletra was administered on: 03/9/23, 03/10/23, 03/11/23, 03/12/23 and 03/13/23. An observation and interview on 03/14/23 at 08:55 AM, inventory of the 300/400 Hall Medication Aide Cart with MA B revealed: An open an in use bottle of Kaletra with Resident #79's first name written on the cap and the altered pharmacy label. The pharmacy label on the bottle had a fill date of 10/06/20, discard by date of 10/06/21 with instructions to take 2 tablets twice daily. The pharmacy on the label was not the location the facility collected the medication from, and the label had been altered by tearing off the patient name and prescriber information. Only 110 pills remained from the initial quantity of 120. 5 doses had been dispensed since Resident #79's order required 2 tablets to be administered at bedtime In an interview with the DON at 09:15 AM, the DON said that the bottle of Kaletra for Resident #79 was not provided by a pharmacy or the resident's family but was instead picked up from a clinic by the Director of Business Development from a clinic and the containers were sealed. The DON said that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 3 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 - Few medications can be received from the facility's contracted pharmacy, the resident's home medications or sometimes from the VA hospital. She said medications are signed for when received from the pharmacy and staff are expected to check the expiration dates, but since Resident #79's Kaletra was not delivered by the pharmacy there was no record of its receipt or the nursing staff that received it. The DON said she did not know if a physician's clinic was an approved source for the acquisition of medications nor could she explain how the facility received and administered expired Kaletra to Resident #79. She said expired medications cannot be used because it becomes less effective and would not treat the patients disease state effective . In an interview on 03/14/23 at 01:00 PM, the Director of Business Development said he was instructed to pick up medication for Resident #79 from a clinic. He said it was the second time he had been to the clinic and when he arrived a receptionist at the front desk handed him a bag with Resident #79's name. The Director of Business development said the bag did not have any kind of prescription details and he did not have to sign for it. In an interview on 03/14/23 at 01:16 PM, the MD said that he does not have a pharmacy or have dispensing authority. He said his practice sometimes gives out samples for his patients but he did not know the sample provided was expired nor a medication previously dispensed to another patient. The MD said the medication given to the facility representative was not dispensed pursuant to a prescription. Record review of the facility policy titled 'Storage of Medications' revised 04/2007 revealed, 3- Drug Containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labels before storing. 4- the pharmacy shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 4 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 0759 Ensure medication error rates are not 5 percent or greater. 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 that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 8 percent based on 3 errors out of 35 opportunities, which involved 3 of 5 residents (Resident #12, Resident #25 and Resident #42) reviewed for medication errors. Residents Affected - Some - Charge Nurse Y failed to ensure Resident #25 received her right dose of fluticasone, a nasal spray used for allergies and congestion, by allowing the resident to self- administer 2 sprays in each nostril instead of 1. - MA A failed to appropriately administer Resident #42's medication as ordered by crushing Metoprolol Succinate ER, an extended release blood pressure medication that should not be crushed. - Charge Nurse Y failed to administer the correct medication to Resident #12 as ordered by administering Multivitamins with Minerals instead of Multivitamin as ordered. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Included: Record review of Resident #25's face sheet dated 03/14/23 revealed, a [AGE] year-old female who admitted to the facility with diagnoses which included: heart failure, type 2 diabetes, and hypertension. Record review of Resident #25's Quarterly MDS dated [DATE] revealed, moderately impaired vision, use of corrective lenses, intact cognition as indicated by a BIMS score of 15 out of 15, use of a wheelchair and supervision with most ADLs. Record review of Resident #25's undated care plan revealed, focus- risk for allergic reaction; interventionmonitor for signs and symptoms of possible allergic reactions such as: hives, rash, swelling, watery eyes, wheezing and report finding to MD as needed. Record review of Resident #25's Physician's Order dated 11/14/22 revealed, Flonase (Fluticasone) 50 mcg1 spray in each nostril 2 times a day. Record review of Resident #25's March 2023 MAR revealed, on 03/14/23 Charge Nurse Y administered Fluticasone 50 mcg to Resident #25. An observation on 03/14/23 at 07:30 AM revealed, Charge Nurse Y preparing medication for administration to Resident #25. She retrieved a bottle of Fluticasone nasal spray, told Resident #25 that it was time for her nasal spray and Charge Nurse Y handed Resident #25 the nasal spray and turned around. Resident #25 self-administered 2 sprays in each nostril while Charge Nurse Y had her back facing the resident. In an interview on 3/14/23 at 11:23 AM, Charge Nurse Y said during medication administration staff must first verify the patient identifiers and then the medications and the orders against the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 5 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She said Resident #25 was alert so she normally administered her own Fluticasone nasal spray. Charge Nurse Y said she would normally inform Resident #25 of her dose of medication, hand the resident the nasal spray and then watch her self-administer 1 spray in each nostril but today she forgot to confirm the dose to be administered to the resident. She said she did not know why she turned her back to Resident #25 and she did not see the resident administer 2 prays instead of 1 spray in each nostril. Charge Nurse Y said that failure to inform residents of the dose to be administered and observe resident's self administer medication places residents at risk of administering the wrong dose which could lead to side effects. Resident #42 Record review of Resident #42's face sheet dated 03/14/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included down syndrome and hypertension. Record review of Resident #42's admission MDS dated [DATE] revealed, use of corrective lenses, severely impaired cognition a indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #42's undated care plan revealed, focus-hypertension r/t abnormal blood pressure reading; goal- remain free of complications related to hypertension; intervention- take blood pressure readings under the same conditions each time if possible. Record review of Resident #42's Physician's Orders dated 01/12/23 revealed, Metoprolol Succinate ER 25 mg- give 1 tableted by mouth one time a day. Record review of Resident #42's Order Summary Report dated 03/14/23 revealed, Resident #42 did not have an order to crush medications. An observation on 03/14/23 at 7:45 AM revealed, MA A preparing medication for administration to Resident #42 she retrieved 1 tablet of Metoprolol Succinate ER 25 mg as well as 2 other solid form medications, crushed them together, mixed then with pudding and administered them to Resident #42. In an interview on 03/14/23 at 11:35 AM, MA A said that ER medications could not be crushed and she did not notice that the prescription of Metoprolol for Resident #42 was an ER tablet. She said ER medications have a special coating that determines how it gets distributed in the body and crushing ER medications placed residents at risk of not getting the desired dose. Resident #12 Record review of Resident #12's face sheet dated 03/14/23 revealed, a [AGE] year-old female admitted to the facility on 07/15/22 with diagnoses which included: quadriplegia, dementia, type 2 diabetes, hypertension, muscle wasting and dysphagia (difficulty swallowing). Record review of Resident #12's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, extensive assistance with most ADLs and use of a wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 6 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #12's undated care plan revealed, focus- requires tube feeding r/t dysphagia, resisting eating and poor po intake. Record review of Resident #12's Physician Order dated 07/15/22 revealed, Multivitamin Tablet- give 1 tablet via G-tube , a tube inserted through the belly that brings nutrition directly to the stomach one time a day for wound healing. An observation on 03/14/23 at 8:43 AM revealed, Charge Nurse Y preparing medication for administration to Resident #12 via G-tube. She retrieved one tablet of Multivitamin with minerals as well as 6 other solid and liquid medications, crushed each medication placed them in individual medication cups and entered into the Resident #12's room. Charge Nurse Y entered into Resident #12's room, dissolved the medications in water and after checking placement of the resident's g-tube she administered the medications with water flushes before and after each medication. In an interview on 03/14/23 at 11:23, Charge Nurse Y said prior to administering medications nursing staff most check the medication against the order to verify accuracy. She said the facility had two types of multivitamins, one with minerals and another without. Charge Nurse Y said she did not notice she gave the vitamins with minerals instead and the 2 multivitamins were not interchangeable. She said administering the wrong multivitamin could place residents at risk of over supplementation. In an interview on 03/14/23 at 11:46 AM, the DON said that prior to administering medications nursing staff must ensure it is the right person, right medication, right dose, right route and right time. She said all medications must be checked against the MAR prior to administration and that Multivitamins with minerals and plain Multivitamins were not the same medication. The DON said medications should be crushed according to the physicians order and ER medications are released into the body for a longer period of time so crushing an ER tablet impacts how the medication is released. She said that all residents must be assessed for self-administration of medications by an interdisciplinary team and she could not find any documentation to prove Resident #12 was assessed for self-administration of medications. The DON said even nursing staff must observe the entire medication administration process to ensure the resident gets the right dose and does not suffer from any adverse reactions. She said failure to administer medications as order could place the resident at risk of not getting the right dose, ineffective therapy or adverse reactions. Record review of Charge Nurse Y's 'Medication Administration Observation Report dated 01/24/23 revealed, 6- correct medication verified by visual check of med label and MAR, competency met. Record review of the facility provided Medications Not To Be Crushed list revised 04/2022 reveal, Metoprolol extended release due to time release and the medication is scored and con be broken in half. Alternate dosage forms e.g., liquids, crushable immediate release tablets . for the product are available. Record review of the facility policy titled Crushing Medications revised 04/2007 revealed, Medications shall be crushed only when its appropriate and safe to do so, consistent with physicians order. 2- the nursing staff and/or consultant shall notify any Attending Physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting, enteric coated medications.) Record review of the facility policy titled Administering Oral Medications revised 10/2010 revealed, 3- place MAR within easy viewing distance; 5- select the drug from the unit dose drawer or stock (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 7 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete supply; 6- check the label on the medication and confirm the medication name and dose with the MAR; 7Check the expiration date on the medication. Return any expired medications to the pharmacy; 8- check the medication dose. Re-check to confirm the proper dose. Record review of the facility policy titled Self-Administration of Medications revised 12/2016 revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe for the resident to do so. Event ID: Facility ID: 675986 If continuation sheet Page 8 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles and stored in locked compartments under proper temperature controls for 2 of 2 medication carts. (300/400 Hall Medication Aide Cart, 300 Hall Nursing Cart) - The facility failed to ensure the 300/400 Hall Medication Aide Cart did not contain medication without appropriate pharmacy labels. - The facility failed to ensure the 300 Hall Nursing Cart did not contain insulin pens with no open date This failure could place residents at risk of adverse medication reactions. Findings included: 300/400 Hall Medication Aide Cart Record review of Resident #79's face sheet dated 03/14/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: dehydration and cellulitis (a bacterial skin infection). The diagnosis list did not include HIV. Record review of Resident #79's admission MDS dated [DATE] revealed, use of corrective lenses, intact cognition as indicated by a BIMS score of 15 out of 15, worsening of behaviors, limited assistance with most ADLs and occasionally incontinent of both bladder and bowel. Record review of Resident #79's undated care plan revealed, focus- impaired immunity related to asymptomatic HIV infection status. Record review of Resident #79's Physician's Orders dated Kaletra (Lopinavir and Ritonavir) 200 mg/50mg, a medication used to treat HIV, take 2 tablets at bedtime. An observation and interview on 03/14/23 at 08:55 AM, inventory of the 300/400 Hall Medication Aide Cart with MA B revealed: - An open an in use bottle of Kaletra with Resident #79's first name written on the cap and the altered pharmacy label. The pharmacy label on the bottle had a fill date of 10/06/20, discard by date of 10/06/21 with instructions to take 2 tablets twice daily . The pharmacy on the label was not the location the pharmacy collected the medication, and the label had been altered by tearing off the patient name and prescriber information. Only 110 pills remained from the initial quantity of 120. MA B said the medication was for Resident #79. She said he had not administered the medication to the resident on 03/14/23, did not know the medication was expired and did not know why the label was altered. MA B said staff are supposed to check their carts daily for expired medications. MA B said when medication expires it could be spoiled, it could no longer be used and must be discarded in the drug disposal bin located in the medication storage room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 9 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 300 Hall Nursing Cart Level of Harm - Minimal harm or potential for actual harm Record review of Resident #100's face sheet dated 03/14/23 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, heart failure and hypertension. Residents Affected - Some Record review of Resident #100's undated care plan revealed, focus- diabetic ulcer r/t diabetes, intervention- monitor blood sugar levels. Record review of Resident #100's Physician's Orders dated 03/06/23 revealed, Insulin Lispro- inject as per sliding scale. Record review of Resident #100's March MAR revealed, on 03/14/23 Resident #100 did not receive Admelog for his 6:30 AM and 11:30 AM doses because his blood sugar was lower than the required sliding scale. Record review of Resident #101's face sheet dated 03/14/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: heart failure and hypertension. There was no included diagnoses of diabetes. Record review of Resident #101's Annual MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15. Record review of Resident #101's undated care plan revealed, focus- diabetes; interventions- diabetes medication as ordered. Record review of Resident #101's Physician's Order dated 02/07/23 revealed, Admelog insulin- inject as per sliding scale. Record review of Resident #101's March MAR revealed, Resident #101 received 2 units of Admelog scheduled for 06:30 AM. An observation and interview on 03/14/23 at 09:00 AM, inventory of the 300/400 Hall Nursing Cart with LVN A revealed: - An open and in use Insulin Lispro pen for Resident #100 with no open date. - An open and in use Insulin Admelog pen for Resident #101 with no open date. LVN A said staff are supposed the check their carts daily for expired and inappropriately labeled medications daily as used. All insulin pens/vials must be labeled with the date opened to track the expiration date because once insulin expires it becomes less efficacious. She said since the pens did not have open dates they could no longer be used and must be discarded in the sharps container and reordered. In an interview on 3/14/23 at 11:46 AM the DON said, nursing staff are expected to check their carts frequently for expired and inappropriately labeled medication. She said once insulin is opened it should be labeled with the open date in order to track its expiration date. She said since the open dates were not present then the pens could not be used because the expiration date could not be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 10 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 determined. The DON said when insulin expires it can lose its efficacy leaving blood sugars untreated. She said all prescriptions should have a pharmacy label that includes patient identifiers, the route of administration, and the dose to be administered. The DON said, if a medication is inappropriately labeled it must be sent back to the pharmacy because use could place residents at risk for medication administration error. Residents Affected - Some Record review of the facility policy titled 'Labeling of Medication Containers' revised 04/2007 revealed, 1-medication labels must be legible at all times. 2- any medication packaging or container that are inadequately or improperly labeled shall return to the issuing pharmacy. 3- Labels for individual drug containers shall include all necessary information such as: resident's name, prescribing physician's name, name/address/telephone number of issuing pharmacy; the name, strength and quantity of the drug, the date the medication was dispensed and directions for use. Record review of the facility policy titled 'Storage of Medications' revised 04/2007 revealed, 3- Drug Containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labels before storing. 4- the pharmacy shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 11 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to adequately equip all residents to call for staff assistance through a communication system for 1 of 24 residents (Resident #1) reviewed for call device. Residents Affected - Few The facility failed to ensure the call device system worked in Resident #1's room. This failure could place residents at risk for delayed care or response in the event of an emergency due to resident being unable to directly contact staff in a timely manner. Findings included: Observation on 03/14/23 at 7:46 a.m., Resident #1 was lying in bed, unable to move self. Resident #1 requested for surveyor to reposition her. Surveyor requested resident to press her call light. Resident said that she cannot work it. Observed residents call light wrapped tightly around partial rail, next to right hand. Resident #1's roommate said that resident's call button does not work. Neither resident sure specifically of how long this has been an issue. Surveyor pressed button then walked outside of the room to check. Surveyor observed that the call light was not on. Upon re-entering the room, resident's roommate said that if the resident needs something, she (the roommate) presses her own call light on the resident's behalf. Surveyor asked if issue has been reported. Roommate said that staff should know because she (roommate) is the one that calls on Resident #1's behalf. Roommate pressed her own call light on behalf of Resident #1. Staff entered room within 2 minutes and provided assistance. Observation and interview on 3/15/23 at 11:40 a.m. Resident #1 was slumped sideways in bed, pillow partially under resident's head and hanging over right side of head and shoulder. Expression of discomfort on Resident #1's face. Roommate was not in room at this time. Surveyor called in aid from hallway, CNA S said she was unaware that the call light was not working. CNA S washed her hands and repositioned resident. CNA S said the consequences of a resident being unable to use call light was the resident could be in trouble and not be able to get help when needed. Observation and interview on 3/15/23 at 12:45 PM, the DON and Charge Nurse Y were in Resident #1's room to check on resident. Charge Nurse Y and the DON said they were not aware the call light was not working. Surveyor requested that they test Resident #1's call light themselves. Asked how do you ensure that call lights are in working order? DON stated that she periodically checks by pressing a call light and timing staff response. Stated she usually does this when there is a problem or complaint. Surveyor asked when is the last time the call light for resident's room was checked? DON stated that it has not been checked lately, maybe 1 to 2 months ago but unsure. DON added that the call light gets checked when an issue is reported. Surveyor asked what could be the result of a resident having a non-functioning call light? DON stated it could be a potentially harmful situation if a resident needed help and could not get it. Interview on 03/15/23 at 12:58 p.m., the Maintenance Manager stated that before today, he had not received a maintenance request for a non-working call light in Resident #1's room. The maintenance manager showed work order app to surveyor; surveyor present when maintenance request came in for call light at 1:00 p.m . Interview on 3/17/23 at approximately 11:45am, administrator states that all call lights are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 12 of 13 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 675986 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 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 0919 expected to be working properly and promptly addressed, if for whatever reason, they fail to work. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's call light policy (revised October 2010) , the purpose of the Answering Call Light policy is to respond to the residents' requests and needs. Per policy, all defective call lights should be reported to the nurse supervisor promptly. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 13 of 13