Inspection·September 25, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed it before this so that I can get my pamper changed. In the past, Resident #5 stated that she had needed her call light at night and could not reach it. She could not recall how many times, but she expressed that it had been more than 3. Resident #5 also stated that she had told her attending nurse that she had not been able to locate the call light for a couple of days. In an observation on 09/13/23 at 10:58am, a staff member from medical records walked into the room and turned the call light off. The investigator informed staff that the resident needed a CNA to assist the resident with changing her diaper. The staff member left the room to find a care staff who worked that hall. In an interview on 09/13/23 at 11:00am, Resident #5 stated I want to be changed so bad, I have needed to be changed for the past hour. In an interview on 09/13/23 at 11:01pm, CNA I came into the room and asked how she could be of assistance. The investigator let the CNA know that Resident #5 needed to be changed. She replied that CNA K was on lunch from 10:45am-11:15am . In an interview on 09/13/23 at 11:06am, CNA K returned from her lunch break early. She stated that as a CNA, she was responsible for changing the beds of residents. After the linen had been changed, she would make sure the call light was clipped to the bed so that residents could reach it. She stated that she could not recall having a conversation with Resident #5 about her call light. In an interview on 09/13/23 at 11:10am, the investigator lead CNA K into Resident #5's room and showed her call light clipped to the [NAME] behind the bed and not clipped to the bed. CNA K stated she may have placed it there on accident, but she would normally clip it to the bed or somewhere in reach. She stated that having the call light in reach was important because if a resident tried to get up and reach the light themselves they could fall. If the light was not in reach, if a resident was having an emergency or feeling bad, they would not be able to get help. CNA K unclipped the call light from the [NAME] and clipped it back to the bed. The interview ended and the investigator stepped out of the room so that CNA K could perform incontinent care for Resident #5. In an interview on 09/13/23 at 1:05pm, the DON stated that CNA's are responsible for changing linen on the beds, but this could be done by anyone in the nursing department. She explained that the call light should be placed within the resident's reach. The risk of not having a call light in reach could be a fall, delay in care, and/or complaints from patients and families. Record review of the facility's policy titled Answering the Call Light, revised March 2012 stated that: (5). When the resident is in bed or confined to a chair, be sure to make sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 2 of 35 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 09/25/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents have the right to be free from neglect for 3 of 11 residents (Resident #1, Resident # 6, and CR #7) reviewed for neglect in that: Residents Affected - Some -The facility system for obtaining medical care for un-witnessed falls was not effective in protecting the health & safety of residents as follows: -The facility failed to transfer Resident #1 to the hospital immediately when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. sustaining a head injury. Resident #1 was receiving the medication Eliquis (blood thinner) and was not transferred to the hospital until 8:00 a.m. Resident #1 is scheduled for surgery on 9/14/23 due to brain bleed. -The NF delayed in calling the physician and sending Resident #6 to a higher level of care to be evaluated when Resident #6 had an unwitnessed fall with head injury on 08/19/2023. -The NF delayed sending CR #7 to a higher level of care when CR #7 had an unwitnessed fall on 08/19/2023 at 6:28am. CR #7 was not sent to the hospital until 12:20pm where it was discovered that CR #7 had a fractured C1 & C2 (neck region). An IJ was identified on 09/21/2023. While the IJ was removed on 09/25/2023, the facility remained out of compliance at a scope of a pattern that is not IJ due to the facility continuing to monitor the implementation and effectiveness of their corrective systems This failure place residents who have unwitnessed falls at risk of increase injury, pain, and death. Findings: Record review of Resident #1 face sheet revealed a 64year old male admitted to the NF on 12/09/2022. Resident #1 diagnoses included the following: hemiplegia (paralysis that affects one side of the body) & hemiparesis (weakness) following cerebral infarction (disrupted blood to the brain), congestive heart failure (when the heart does not pump blood adequately), atrial fibrillation (irregular heartbeat), cognitive communication deficit (impairment in an individual's mental capacity), muscle weakness, hyperlipidemia (elevated cholesterol), and hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 11(signifying mild mental impairment). Further review revealed that resident required limited assistance with bed mobility, transfer, and personal hygiene. Further review revealed that resident required supervision with dressing, eating, and toilet use. Record review of Resident #1s' Physician Orders revealed the following orders: -aspirin oral tablet 325mg give 1 tablet by mouth every 6 hours as needed for pain, order date 08/04/2023, -Eliquis oral tablet 2.5mg give 1 tablet by mouth two times a day for atrial fibrillation, order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 3 of 35 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 09/25/2023 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 0600 date 02/17/2023. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's MAR dated September 2023 revealed that the NF was administering the medication aspirin and Eliquis as ordered by the physician. Record review of Resident #1's Nursing Progress Notes revealed the following: Residents Affected - Some -dated 09/11/2023 documented by RN A at 5:50am the following: .Called NF transportation for patient pick up time within 1 to 1.5 hour arrival . -documented by LVN D on 09/11/2023 at 8:08am: .Resident left facility via EMS regular transportation with family member .swelling noted left .and skin tear to right knee .resident alert and responsive . Record review of Resident #1's hospital records dated 09/11/2023 revealed that a CT (computerized x- ray) of the head without contrast was done with the following: Intra orbital (foreign object inside of a space caused by a trauma) hemorrhage (bleeding) in the left orbit with periorbital tissue swelling and mild proptosis .mildly depressed left medial orbital wall fracture .bilateral nasal bone fracture with overlying soft tissue swelling. Interview on 09/13/2023 at 12:55 p.m., RN A said he worked on 09/10/2023 the 6pm-6am shift and was Resident #1's nurse. RN A said he found Resident #1 on the floor in his room at the foot of his bed laying on his right side. RN A said the time was around 4am-5am. RN A said Resident #1 told him that he was trying to transfer himself from his wheelchair to his bed. RN A said Resident #1 told him that he had hit his head. RN A said he did not see any signs of injury such as a knot on the head or any bleeding. RN A said resident was placed back in his wheelchair with the assistance of a CNA who name he could not remember. RN A said he called the family of Resident #1 as well as the doctor who gave the order to send resident to the hospital. RN A said regular transportation was call to transport resident to the hospital instead of 911 services because Resident #1 vital signs was stable, there was no bleeding, and resident was conscious. Further interview with RN A said he was not aware that Resident #1 was receiving the blood thinner Eliquis twice a day. RN A said if a resident experienced a fall with a head injury and receiving blood thinners should be transported to the hospital immediately for further evaluation because resident could be bleeding internally. Interview on 09/13/2023 at 1:40 p.m., family member of Resident #1 said resident was still at the hospital experiencing bleeding from the brain. The family member said Resident #1 was scheduled to have surgery on 09/14/2023 to relieve the pressure. The family member said the NF called her a little after 5:00 a.m. informing her that Resident #1 had fallen. The family member said she made it to the NF around 5:40 a.m. and that Resident #1 was complaining of pain to the right side of his neck and back, and left side of his head. The family member said Resident #1 left side of face was swelling extending from the forehead near the left eye. The family member said there was no sense of urgency to transport Resident #1 to the hospital. The family member said she went to let a male nurse know Resident #1 had swelling to his head. The family member said when the male nurse looked at Resident #1, he admitted resident had swelling to his head and told her that help was on the way. The family member said she then went to the nurse station and spoke to a female nurse asking when Resident #1 was going to be transported to the hospital. The family member said the female nurse told her that she had called transportation and was told that that they were in route to the NF. The family member (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 4 of 35 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 09/25/2023 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 0600 said it was after 8:00am when Resident #1 left the NF on the way to the hospital. Level of Harm - Immediate jeopardy to resident health or safety Interview on 09/13/2023 at 2:02 p.m., the Unit Manager said she worked at the NF from 8am-5pm. The Unit Manager said on 09/11/2023 she arrived at the NF around 7:45am and began making rounds on the Hallways. The Unit Manager said she saw Resident #1 family member at the nurse station asking when the ambulance was coming to take resident to the hospital because he had experienced a fall in his room. The Unit Manager said when she arrived at Resident #1's room, resident was sitting in his room in his wheelchair. The Unit Manager said Resident #1 was not able to tell her what had happen to him. Residents Affected - Some The Unit Manager said she learned that Resident #1 had fallen on the 10pm-6am. The Unit Manager said the nurse on the night shift (10pm-6am) had already given report to the oncoming LVN D who was working the morning shift. The Unit Manger said in the event of an emergency the Nursing staff would call 911 services and not the NF transportation System (non-emergency). Interview on 09/14/2023 at 1:17 p.m., the DON said according to the Nursing Progress Notes, Resident #1 was in his wheelchair and tried to transfer on his own to his bed fell and hit his head. The DON said resident was transferred to the hospital and resident family member was with him. The DON said she spoke with RN A who said Resident #1 was yelling for help. The DON said when RN A arrived at Resident #1's room, resident was on the floor reporting that he had hit his head. The DON said RN A assessed Resident #1 and done ROM on resident along with offering the resident something for pain. The DON said based on the Nursing documentation, Resident #1 was not in any pain. The DON said she learned later from the hospital that Resident #1 CT scan of the head was positive for hemorrhage (bleeding). The DON said she informed the Administrator of the hospital findings, and the Administrator called the incident in to the state. The DON said the NF initiated in-service with the staff on fall precautions, abuse, and neglect based on the NF policy. The DON said she was aware that Resident #1 was on a blood thinner and was transported to the hospital via the NF transportation. The DON said it was a case by case (pending on the resident (s) level of consciousness, vital signs, pain, distress, etc.) that determined if a resident is sent out by normal transportation or 911 services. The DON said the NF transportation could take up to 1- 2 hours to transport a resident to the hospital. The DON said she was aware that it took the NF almost 4 hours to send resident to higher level of care. The DON said she could not say if the course of action taken regarding Resident #1's unwitnessed fall with a head injury receiving blood thinners was right or wrong course of action and again that it was a case-by-case situation. The surveyor asked the DON what was the NF policy regarding a resident on blood thinners experiencing a fall with head injuries? The DON said she did not know what the NF policy was on falls with head injuries in relation to residents taking anticoagulants/blood thinners and would have to go read it. Further interview with the DON said the NF did not have a policy regarding falls as it relates to blood thinners. The DON was asked for the NF Policy on Abuse and Neglect. The NF provided the surveyor a Policy on Abuse Investigation and Report. Interview on 09/15/2023 at 12:22 p.m., LVN D said she worked the morning shift full time. LVN D said RN A gave her report on 09/11/2023 at 6:30 a.m. LVN D said RN A reported that Resident #1 had fallen in his room. LVN D said she asked RN A if he had called 911 services and RN A said no. LVN D said when she assessed Resident #1, resident left eye was swollen and he had a skin tear to his right knee. LVN D said Resident #1 could not tell her exactly what had happened just that he had fallen on the floor. Resident #6 Record review of Resident #6 face sheet revealed an [AGE] year-old male admitted to the NF on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 5 of 35 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 09/25/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 05/01/2019 with the following diagnoses that included: nontraumatic subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain-08/25/2023), cerebral infarction (disruption of blood flow to the brain, Parkinson's Disease (disorder that effects movement), contracture (shortening and hardening of the muscles), history of falling, heart failure, hypertension (high blood pressure), hypotension (low blood pressure), dementia (impairment of the brain causing memory loss and judgement), and metabolic encephalopathy (disorder of the brain caused by a chemical imbalance in the blood). Record review of Resident #6's MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition level was severely impaired. Further review revealed that Resident #6 required extensive assistance with bed mobility, transfer, dressing, eating, and total assistance with toileting and personal hygiene. Record review of Resident #6's Care Plan dated 02/24/2023, revealed that resident was being care planned for falls related to poor balance dated 07/04/2023 with an intervention that included keep resident on visible area for close monitor. Record review of Resident #6's Nursing Progress Notes dated 08/19/2023 documented by LVN M at 5:21p.m., revealed in part: .Resident observed on the floor at the top of the 200 hallway. He is observed face down on the floor, in front of his wheelchair. He was assessed for injuries and pain, then assisted back into his wheelchair x 3 staff. He is noted with a small amount of running, bright red blood coming out of his nose, nose pinched together for a few seconds, bleeding stopped, no visible injuries noted. Family member arrived shortly afterward and were informed of the incident and requested an ice pack to apply to his nose. A few minutes later, family member requested would like for resident be transported to the hospital to have a CT SCAN. Regular EMS phoned to transport resident to hospital .5:53pm regular transportation here to transport resident to the hospital per family request . Record review of Resident #6 hospital records dated 08/19/2023 indicated that a CT of the head was done with the following impression: right frontal contusion (injured skin or tissue where blood vessels have burst suddenly) .small volume subarachnoid hemorrhage . Record review of the NF investigation report dated 09/11/2023revealed that Resident #6's CT scan at the hospital showed that resident had a displaced fracture in the right frontal calvarium (skull) with extension into the right orbital (bony space that contains the eyeball) roof. Interview on 09/19/2023 at 1:27 p.m., the RP of Resident #6 said she did not receive a call from the NF regarding resident fall. The RP said when she arrived at the NF, resident had redness, bruising, and swelling to the side of his eye, could not remember which eye it was. The RP said she had to request that Resident #6 be sent out to the hospital. The RP said it took the NF about 30 minutes to transport resident to the hospital. Interview on 09/19/2023 at 2:32 p.m., LVN M said she worked at the NF on weekends part time 6am-6pm shift. LVM M said on 08/19/2023 she was called by RN N telling her that Resident #6 was on the floor and that resident had been placed back in his wheelchair. LVN M said when she saw resident, he was sitting in his wheelchair with blood on the side of his nose as well as on the outside of his nose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 6 of 35 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 09/25/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety LVN M said she pinched resident nostrils and cleaned it with a wet towel and the bleeding stopped. LVN M said she assessed resident for injuries and initiated neuro checks on resident. LVN M said she called the RP and the doctor. LVN M said the RP wanted to send resident out to the hospital. LVN M told the surveyor what all took place around Resident #6 fall on 08/19/2023 was documented in the nurse's notes. LVN M said the last time she received in-service on falls was last week but could not remember the last time she received in- services on unwitnessed falls. Residents Affected - Some Interview on 09/19/2023 at 7:17 p.m., RN N said he observed Resident #6 on hall 200 near his room in the hallway close to the nurse station. RN N said resident was sitting in his wheelchair bleeding from his nostrils with LVN and a CNA standing around resident. RN N said he was trying to stop the bleeding coming from resident nostrils which he was able to stop the bleeding. RN N said Resident #6 was not complaining of pain, but his words were not clear, and that resident spoke in allow tone. RN N said he did not notify the doctor. RN N said he assumed that the primary care nurse called the doctor and the RP. Resident CR #7 Record review of CR #7's face sheet revealed a [AGE] year-old female admitted to the NF on 12/08/2021 diagnoses that included the following: Alzheimer's Disease, nontraumatic subarachnoid hemorrhage from right middle cerebral artery, encephalopathy (brain disease that alters the brain function), dementia (loss of memory and judgement), insomnia (difficulty falling asleep), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), rheumatoid arthritis(Disorder affecting many joints including the hands and feet), and muscle weakness. Record review of CR #7's x-ray of the spine cervical 2-3 views dated 02/27/2023 impression revealed: mild arthritis and loss of the normal cervical lordosis (condition that pushes the neck further forward than it should be or usually is). Record review of CR #7's MDS dated [DATE] revealed that CR #7 had BIMS score of 5 indicating that CR #7's cognition was severely impaired. Further review revealed that CR #7 required supervision with bed mobility, transfer, eating, and toilet use. Further review revealed that CR #7 required limited assistance with dressing and personal hygiene. Record review of CR #7's Care Plan dated 12/15/2021 and revised 08/28/2023 revealed that resident was being care planned for falls and having an actual fall on 08/19/2023 and revised 08/28/2023 with an intervention that included the following: observe/document/report to MD as needed for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further record of CR #7's Care Plan did not reveal that CR #7 was being care planned for or loss of the normal cervical lordosis. Record review of CR #7's Nursing Progress Notes revealed in part: Documented by LVN G on 08/19/2023 at 6:28am .Resident noted lying on floor with blanket and pillow. When asked why she was on the floor, resident replied I am tired and want to sleep here .Resident educated to sleep in bed and not on floor. Resident assisted from floor to bed via staff .Resident resting quietly . Documented by LVN O on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 7 of 35 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 09/25/2023 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 0600 08/19/2023 at 10:24 a.m., revealed in part: Level of Harm - Immediate jeopardy to resident health or safety .Resident reported to this nurse that she fell on the floor during 10pm-6am shift. Resident is complaining of neck pain, bruises also noted on the left elbow. Residents Affected - Some Resident also reported biting her tongue. NP in the building and notified . At 10:34 a.m. New order for X-ray left elbow, radius and humerus, left shoulder. X-ray called with the x-ray order . Documented by the DON dated 08/19/2023 at 10:52am revealed in part: .Resident was found sleep on the floor next to her bed .now she is complaining of pain .The NP at the facility give new order for place C-collar (cervical/neck brace) send to hospital for fall and c/o neck pain do not move pt/or stand . Documented by LVN O on 09/18/2023 at 12:20pm revealed in part: 911 call placed, EMS and transferred resident to the hospital .C collar in place . Record review of the NF Investigation report dated 08/19/2023 revealed that CR #7 was observed laying on floor, complained of pain, sent to the hospital and MRI revealed that that CR #7 had mildly displaced acute fractures of the anterior arch of C1 and C2. Interview on 09/14/2023 at 10:54 a.m., the hospital staff RNZZ said CR #7 was admitted to the hospital with a cervical fracture on 08/19/2023. RN ZZ said CR #7 was transferred to SICU and later to hospice services. RN ZZ said CR #7 passed away on 08/29/2023. Interview on 09/14/2023 at 12:20 p.m., the Administrator said CR #7 had a fall and was sent to the hospital. The Administrator said it was discovered at the hospital that CR #7 had a neck fracture. The Administrator said while CR #7 was at the hospital she developed pneumonia as well. The Administrator said CR #7 had been placed on in-patient hospice. Interview on 09/18/2023 at 11:23 a.m., LVN G said she worked on 08/19/2023 on the 10pm-6am shift. LVN G said when she arrived at work, CR #7 was sitting in her wheelchair at the front entrance and did not agree to go to bed until 3:00 a.m. LVN G said she made rounds on the residents around 5:00 a.m. and that CR #7 was resting in bed. LVN G said she made her last rounds on the residents at 6:00 a.m., and when she arrived at CR #7's room, CR #7 was on the floor on the left side of her bed wrapped in a blanket with a pillow resting under her head. LVN G said CR #7 said she wanted to lay on the floor. LVN G said she told CR #7 no and that she needed to get back in the bed. LVN G said she checked CR #7 for range of motion with no complaints of discomfort. LVN G said she called for help and that. LVN H with the assistance of the CNA, CR #7 was put back in bed. LVN G said she had been working at the NF for 3 years but practicing as a nurse for 7 months. LVN G said when a resident with confusion was found on the floor and no one know what happened, the course of action to take was to do range of motion assessing for pain. LVN G said she did not do a complete head to toe skin assessment before placing CR #7 back in bed. LVN G said she had been in- serviced on falls and that it was okay to move a resident with an unwitnessed fall after assessing their range of motion. LVN G said it was okay to move a resident that was conscious but not a resident that was unconscious. LVN G said she was not aware of the NF policy on un-witnessed falls. LVN G said she was just trying to keep CR #7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 8 of 35 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 09/25/2023 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 0600 comfortable. LVN G said it was not normal behavior for CR #7 to lay on the floor. Level of Harm - Immediate jeopardy to resident health or safety Interview on 09/18/2023 at 12:55 p.m., LVN O said she worked the weekend shift 6am-10pm and was the nurse that relieved LVN G on 08/19/2023. LVN O said she had received in report from LVN G letting her know that CR #7 was found on the floor with no injuries and that LVN G had initiated neuro checks. LVN O said when she arrived at CR #7 room, CR #7 was in bed and denied pain. LVN O said she continued the neuro checks per facility protocol and that when she returned to CR #7 room again, CR #7 was complaining of elbow pain. LVN O said she could not remember which elbow it was but noticed a little red bruise to the elbow. LVN O said at this time (could not remember the time), the NP was at the NF. LVN O said later, CR #7 started to complain of pain to her neck. LVN O said the NP assessed CR #7 asking resident to turn her neck, but CR #7 was unable to turn her neck. Residents Affected - Some LVN O said the NP gave orders to place a C collar on resident neck and send to the hospital. Further interview on 09/18/2023 at 12:55 p.m., LVN O said she had been in- serviced on falls to check the resident status of orientation, if confused do not move the resident because resident may have injured themselves. LVN O said resident would be sent to the hospital for further evaluation. Interview on 09/18/2023 at 1:35 p.m., LVN H said she worked the night shift 10pm- 6am full time. LVN H said when CR #7 was found on floor in her room with pillow under head, she assisted LVN G along with the CNA in placing CR #7 back in bed. LVN H said CR #7 did not complain of pain. LVN G said the doctor and RP needed to be notified immediately about a fall witnessed or unwitnessed. Interview on 09/19/2023 at 11:10 a.m., CNA Q said she worked the 10pm-6am shift and was the CAN for CR #7. CNA Q said she was coming up the hallway around 5:45am-6:00am making her last rounds on the resident when she saw the nurse in CR #7 room. CNA Q said when she arrived at CR #7's room, CR #7 was on the floor with her bed in the. CNA Q said CR #7 was asked where she was going but CR #7 could not say. CNA Q said resident was not complaining of pain. CNA Q said right after she assisted with placing CR #7 back in bed, CR #7 began to complain of pain saying that her neck hurt. Record revie of the NF Policy on Anticoagulant-Clinical Protocol revised April 2007 revealed in part: .The staff and physician will identify and address potential complications in individuals reveiving anticoagulation . Record review of the NF Policy on Falls revised September 2012 revealed in part: .The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls (for example, increase fracture risk in someone with osteoporosis or increase risk of bleeding in someone taking an anticoagulant). The Administrator was notified on 09/21/00 at 3:04 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on 09/21/202300 at 3:04 PM and a Plan or Removal (POR) was requested. The facility POR was accepted on 09/24/202300 at 3:00p.m. and indicated: PLAN OF REMOVAL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 9 of 35 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 09/25/2023 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 0600

F600 Level of Harm - Immediate jeopardy to resident health or safety Name of facility: Park Manor Cypress Station Date: 09/21/2023 Residents Affected - Some Impact Statement: On 9/21/23 the state surveyor entered to continue an abbreviated survey at Park Manor of Cypress Station at 420 Lantern Bend Dr, Houston, Texas 77090. On 9/21/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure of the to ensure each resident was free from neglect. Immediate Action How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all unwitnessed falls in residents with head injury in the last 30 days to ensure the residents received treatment and care in accordance with professional standard of practice. All residents with unwitnessed falls have the potential to be affected by this deficient practice, no other residents were identified as being affected. Audit completed on 9/21/2023 by Director of Nursing. What corrective actions have been implemented for the identified resident? Resident CR # 7 was discharged to hospital on 8/19/2023. Resident #6 readmitted to facility and is in stable condition. Resident #1 re-admitted to facility on 9/19/2023 in stable condition and had care plan updated with the fall preventions interventions. Nurses on duty for the above residents received 1:1 in-service by Director of Nursing on unwitnessed fall protocol that included the assessment of resident and following the Care Path Fall Tool attached. CNAs were in-serviced by Director of Nursing on fall protocol that included not to move a resident post fall and to immediately notify the license nurse to assess resident. What corrective actions were taken? 3. The following actions were initiated immediately on 9/21/23 c. On 9/21/23 an audit was completed by the Director of Nursing and/or designee to identify all unwitnessed falls in the last 30 days to ensure these residents received treatment and care in accordance with professional standard of practice. No residents were identified to be affected by deficient practice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 10 of 35 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 09/25/2023 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 0600 d. Level of Harm - Immediate jeopardy to resident health or safety Director of Nursing was educated on 9/21/23 by Clinical Services Director on signs and symptoms of neglect, reporting neglect, Abuse Coordinator and protocol an unwitnessed fall with/or suspected major/serious injuries are sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Residents Affected - Some e. Initiated in-services on 9/21/23 with licensed nurses by Director of Nursing /Designee on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until in-service is completed on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Nursing staff was in-serviced on fall interventions on 9/22/2023 by Director of Nursing. Fall interventions are entered for each resident in their care plan that is easily accessible to nurses via PCC care plan tab and for CNAs under Kardex in their POC documentation tool for each resident. Nursing staff was in-serviced on these tools on 9/22/2023 by Director of Nursing. 4. How will the system be monitored to ensure compliance? a. The Director of Nurses/Administrator will review falls in morning meeting starting on 9/22/23 and ongoing to ensure no neglect occurred on unwitnessed falls with/or suspected major/serious injury. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The weekend supervisor and/or designee was in-serviced on 9/21/23 by Director of Nursing/ Designee on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. The Weekend Manager will monitor compliance during Saturdays and Sundays and ensure no neglect occurred on unwitnessed falls with/or suspected major/serious injury. c. Newly hired staff and PRN staff will be educated by the Director of Nursing/Designee on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 11 of 35 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 09/25/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety resident assessment by licensed nurse using the Care Path Fall Tool attached. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Residents Affected - Some Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 9/21/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan that includes the Fall Policy updated on neglect policy and fall protocol including unwitnessed falls with/or without injuries. Unwitnessed falls be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 09/24/2023 at 11:36am RN P said she worked the 6am-6pm shift and had been in-serviced on abuse and neglect, falls unwitnessed or witnessed and the resident on anticoagulants that experienced injury especially head injury to send resident out to the hospital via 911 services. Interview on 09/24/2023 at 11:42am LVN RR said she worked at the NF PRN on the 6am- 2pm shift. LVN RR said she had been in-serviced on abuse and neglect, falls assessing residents with witnessed and un-witnessed falls. LVN RR said after assessing the resident and there are complaints of pain do not move the resident, check to see if the resident is on any blood thinners, send to the hospital via 911 for further evaluation, notifying the doctor and the RP. Interview on 09/24/2023 at 11:50am LVN R said she worked at the NF full time 8am-5pm. LVN RR said she had been in-serviced on falls witnessed and unwitnessed to do a head-to-toe assessing for pain or any injuries. LVN R said if the resident hit their head neuro checks had to be initiated per facility protocol. LVN RR said she was in-serviced to check to see if the resident was on any blood thinners and prepare to send the resident to the hospital 911. LVN RR said if an injury is suspected, do not move the resident, and send to hospital 911 for further evaluation being sure to notify the doctor and RP and document all actions taken. Interview on 09/24/23 at 12:00pm CNA S said she worked at the NF full time on the weekends 6am-10pm and had been in-serviced on falls. CNA S said if a resident had fall that was witnessed or un-witnessed do not move the resident and get the nurse right away to assess the resident. Interview on 09/24/2023 at 12:05pm CNA V said she worked the 6am-2pm shift and had been in-serviced on abuse a[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 12 of 35 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 09/25/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 11 residents (Resident #1) reviewed for quality of care in that: Residents Affected - Some -The facility failed to transfer Resident #1 to the hospital in a timely manner when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. and sustained a head injury. Resident #1 was receiving Eliquis (blood thinner). Resident #1 was not transferred to the hospital until after 8:00 a.m. Resident #1 is scheduled to have surgery on 9/14/23 due to brain bleed. - The facility failed to call 911 services to transport Resident #1 to a higher level of care instead, used their non-emergency transportation to send resident to the hospital. -The NF delayed in calling the physician and sending Resident #6 to a higher level of care to be evaluated when Resident #6 had an unwitnessed fall with head injury on 08/19/2023. -The NF delayed sending CR #7 to a higher level of care when CR #7 had an unwitnessed fall on 08/19/2023 at 6:28am. CR #7 was not sent to the hospital until 12:20pm where it was discovered that CR #7 had a fractured C1 & C2 (neck region). An Immediate Jeopardy (IJ) was identified on 09/14/2023. While the IJ was removed on 09/17/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place residents that sustain a fall with head injuries on blood thinners at risk for delayed treatment that could lead to severe injury, intracranial hemorrhage and/or death. Findings Record review of Resident #1 face sheet revealed a [AGE] year-old male admitted to the NF on 12/09/2022. Resident #1 diagnoses included the following: hemiplegia (paralysis that affects one side of the body) & hemiparesis (weakness) following cerebral infarction (disrupted blood to the brain), congestive heart failure (heart does not pump blood as well as it should), atrial fibrillation (irregular heartbeat), cognitive communication deficit (impairment in an individual's mental capacity), muscle weakness, hyperlipidemia (elevated cholesterol), and hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 11(signifying mild mental impairment). Further review revealed that resident required limited assistance with bed mobility, transfer, and personal hygiene. Further review revealed that resident required supervision with dressing, eating, and toilet use. Record review of Resident #1s' Physician Orders revealed the following orders: -aspirin oral tablet 325mg give 1 tablet by mouth every 6 hours as needed for pain, order date 08/04/2023, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 13 of 35 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 09/25/2023 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 0684 -Eliquis oral tablet 2.5mg give 1 tablet by mouth two times a day for atrial fibrillation, order date 02/17/2023. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's MAR for the month of September 2023 revealed the resident was receiving the medication aspirin and Eliquis as ordered by the physician. Residents Affected - Some Record review of Resident #1's Care Plan revealed that resident was care planned for falls dated 02/24/2023 with an intervention to determine possible causative factors and implement interventions. Further review revealed that Resident #1 was care planned for anticoagulant therapy dated 01/31/2023 with interventions that included administer medication as ordered, labs as ordered, reporting abnormal lab results, and report skin abnormalities. Record review of Resident #1's Nursing Progress Notes revealed the following: -dated 09/11/2023 documented by RN A at 5:50 am the following: .Called NF transportation for patient pick up time within 1 to 1.5 hour arrival . -dated 09/11/2023 documented by Unit Manager at 6:28a.m. .This writer making rounds, observed resident sitting in his wheelchair on the side of his bed. Noted with raised area above left eye. Resident verbal and able to express needs at this time. EMS in route for transport to ER. -documented by LVN D on 09/11/2023 at 8:08 am: .Resident left facility via EMS regular transportation with family member .swelling noted left .and skin tear to right knee .resident alert and responsive . LVN D documentation did not specify what he meant when he documented left. Record review of Resident #1's hospital records dated 09/11/2023 [AGE] year-old admitted to the emergency department form NF for fall on Eliquis. Patient reports that he was standing up whenever he slipped on his socks and fell, hitting his head. Did not lose consciousness. Complaining of neck pain and right shoulder pain. Brought to the emergency department via EMS. No interventions prior to arrival. C-collar placed on arrival to the emergency department .CT (computerized x- ray) of the head without contrast was done with the following: Intra orbital (foreign object inside of a space caused by a trauma) hemorrhage (bleeding) in the left orbit with periorbital tissue swelling and mild proptosis .mildly depressed left medial orbital wall fracture .bilateral nasal bone fracture with overlying soft tissue swelling. Further review revealed that severe spinal stenosis secondary to DISH (Diffuse idiopathic skeletal hyperostosis-condition affecting the spine). Plan is tentatively for OR (Operating Room) tomorrow. Interview on 09/13/2023 at 12:55 p.m., RN A said he worked on 09/10/2023 the 6pm-6am shift and was Resident #1's nurse. RN A said he found Resident #1 on the floor in his room at the foot of his bed laying on his right side. RN A said the time was around 4am-5am. RN A said Resident #1 told him that he was trying to transfer himself from his wheelchair to his bed. RN A said he did range of motion on Resident #1 and that he could move his extremities without complaints of pain. RN A said he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 14 of 35 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 09/25/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some initiated neuro checks. RN A said Resident #1 told him that he had hit his head. RN A said he did not see any signs of injury such as a knot on the head or any bleeding. RN A said resident was placed back in his wheelchair with the assistance of a CNA who name he could not remember. RN A said he called the family of Resident #1 as well as the doctor who gave the order to send resident to the hospital. RN A said regular transportation was called to transport resident to the hospital instead of 911 services because Resident #1's vital signs was stable, there was no bleeding, and resident was conscious. Further interview with RN A said he was not aware that Resident #1 was receiving the blood thinner Eliquis twice a day. RN A said if a resident experienced a fall with a head injury and receiving blood thinners they should be transported to the hospital immediately for further evaluation because resident could be bleeding internally. Interview on 09/13/2023 at 1:40 p.m., family member of Resident #1 said resident was still at the hospital experiencing bleeding from the brain and that the hospital said they were going to have to do surgery on the neck to relieve some pressure. The family member said Resident #1 was scheduled to have surgery on 09/14/2023 to relieve the pressure. The family member said the NF called her a little after 5:00 a.m. informing her that Resident #1 had fallen. The family member said she made it to the NF around 5:40 a.m. and that Resident #1 was complaining of pain to the right side of his neck and back, and left side of his head. The family member said Resident #1 left side of face was swelling extending to the forehead near the left eye. The family member said there was no sense of urgency to transport Resident #1 to the hospital. The family member said she went to let a male nurse know Resident #1 had swelling to his head. The family member said when the male nurse looked at Resident #1, he admitted resident had swelling to his head and told her that help was on the way. The family member said she then went to the nurse station and spoke to a female nurse asking when Resident #1 was going to be transported to the hospital. The family member said the female nurse told her that she had called transportation and was told that that they were in route to the NF. The family member said it was after 8:00 a.m. when Resident #1 left the NF on the way to the hospital. Interview on 09/13/2023 at 2:02 p.m., the Unit Manager said she worked at the NF from 8am-5pm and had been working at the NF for 11 years. The Unit Manager said on 09/11/2023 she arrived at the NF around 7:45 a.m. and began making rounds on the Hallways. The Unit Manager said she saw Resident #1's family member at the nurse station asking when the ambulance was coming to take resident to the hospital because he had experienced a fall in his room. The Unit Manager said when she arrived at Resident #1's room, resident was sitting in his room in his wheelchair. The Unit Manager said Resident #1 was not able to tell her what had happened to him. The Unit Manager said she learned that Resident #1 had fallen on the 10pm-6am shift. The Unit Manager said the nurse on the night shift (10pm-6am) had already given report to the oncoming nurse LVN D who was working the morning shift. The Unit Manger said in the event of an emergency the Nursing staff would call 911 services and not the NF transportation System (non-emergency). An attempted interview and observation on 09/14/2023 at 10:31a.m. with Resident #1 was unsuccessful due to hospital staff informing the surveyor that Resident #1 was in surgery. Interview on 09/14/2023 at 1:17 p.m., the DON said according to the Nursing Progress Notes, Resident #1 was in his wheelchair and tried to transfer on his own to his bed fell and hit his head. The DON said resident was transferred to the hospital and resident family member was with him. The DON said she soke with RN A who said Resident #1 was yelling for help. The DON said when RN A arrived at Resident #1's room, resident was on the floor reporting that he had hit his head. The DON said RN A assessed Resident #1 and done ROM on resident along with offering the resident something for pain. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 15 of 35 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 09/25/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some DON said based on the Nursing documentation, Resident #1 was not in any pain. The DON said she learned later from the hospital that Resident #1 CT scan of the head was positive for hemorrhage. The DON said she informed the Administrator of the hospital findings, and the Administrator called the incident in to the state. The DON said the NF initiated in-service with the staff on fall precautions and abuse and neglect based on the NF policy. The DON said she was aware that Resident #1 was on a blood thinner and was transported to the hospital via the NF transportation. The DON said it was a case by case (pending on the resident (s) level of consciousness, vital signs, pain, distress, etc.) that determined if a resident is sent out by normal transportation or 911 services. The DON said the NF transportation could take up to 1- 2 hours to transport a resident to the hospital. The DON said she was aware that it took the NF almost 4 hours to send resident to higher level of care. The DON said she could not say if the course of action taken regarding Resident #1's unwitnessed fall with a head injury receiving blood thinners was the right course of action and again that it was a case-by-case situation. The surveyor asked the DON what was the NF policy regarding a resident on blood thinners experiencing a fall with head injuries? The DON said she did not know what the NF policy was on falls with head injuries in relation to residents taking anticoagulants/blood thinners and would have to go read it. Further interview with the DON said the NF did not have a policy regarding falls as it relates to blood thinners. Interview on 09/15/2023 at 12:22 p.m., LVN D said she worked the morning shift full time. LVN D said RN A gave her report on 09/11/2023 at 6:30 a.m. LVN D said RN A reported that Resident #1 had fallen in his room. LVN D said she asked RN A if he had called 911 services and RN A said no. LVN D said when she assessed Resident #1, the resident's left eye was swollen, and he had a skin tear to his right knee. LVN D said Resident #1 could not tell her exactly what had happened just that he had fallen on the floor. Resident #6 Record review of Resident #6 face sheet revealed an [AGE] year-old male admitted to the NF on 05/01/2019 with the following diagnoses that included: nontraumatic subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain-08/25/2023), cerebral infarction (disruption of blood flow to the brain, Parkinson's Disease (disorder that effects movement), contracture (shortening and hardening of the muscles), history of falling, heart failure, hypertension (high blood pressure), hypotension (low blood pressure), dementia (impairment of the brain causing memory loss and judgement), and metabolic encephalopathy (disorder of the brain caused by a chemical imbalance in the blood). Record review of Resident #6's MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition level was severely impaired. Further review revealed that Resident #6 required extensive assistance with bed mobility, transfer, dressing, eating, and total assistance with toileting and personal hygiene. Record review of Resident #6's Care Plan dated 02/24/2023, revealed that resident was being care planned for falls related to poor balance dated 07/04/2023 with an intervention that included keep resident on visible area for close monitor. Record review of Resident #6's Nursing Progress Notes dated 08/19/2023 documented by LVN M at 5:21p.m., revealed in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 16 of 35 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 09/25/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some .Resident observed on the floor at the top of the 200 hallway. He is observed face down on the floor, in front of his wheelchair. He was assessed for injuries and pain, then assisted back into his wheelchair x 3 staff. He is noted with a small amount of running, bright red blood coming out of his nose, nose pinched together for a few seconds, bleeding stopped, no visible injuries noted. Family member arrived shortly afterward and were informed of the incident and requested an ice pack to apply to his nose. A few minutes later, family member requested would like for resident be transported to the hospital to have a CT SCAN. Regular EMS phoned to transport resident to hospital .5:53pm regular transportation here to transport resident to the hospital per family request . Record review of Resident #6 hospital records dated 08/19/2023 indicated that a CT of the head was done with the following impression: right frontal contusion (injured skin or tissue where blood vessels have burst suddenly) .small volume subarachnoid hemorrhage . Record review of the NF investigation report dated 09/11/2023revealed that Resident #6's CT scan at the hospital showed that resident had a displaced fracture in the right frontal calvarium (skull) with extension into the right orbital (bony space that contains the eyeball) roof. Interview on 09/19/2023 at 1:27 p.m., the RP of Resident #6 said she did not receive a call from the NF regarding resident fall. The RP said when she arrived at the NF, resident had redness, bruising, and swelling to the side of his eye, could not remember which eye it was. The RP said she had to request that Resident #6 be sent out to the hospital. The RP said it took the NF about 30 minutes to transport resident to the hospital. Interview on 09/19/2023 at 2:32 p.m., LVN M said she worked at the NF on weekends part time 6am-6pm shift. LVM M said on 08/19/2023 she was called by RN N telling her that Resident #6 was on the floor and that resident had been placed back in his wheelchair. LVN M said when she saw resident, he was sitting in his wheelchair with blood on the side of his nose as well as on the outside of his nose. LVN M said she pinched resident nostrils and cleaned it with a wet towel and the bleeding stopped. LVN M said she assessed resident for injuries and initiated neuro checks on resident. LVN M said she called the RP and the doctor. LVN M said the RP wanted to send resident out to the hospital. LVN M told the surveyor what all took place around Resident #6 fall on 08/19/2023 was documented in the nurse's notes. LVN M said the last time she received in-service on falls was last week but could not remember the last time she received in- services on unwitnessed falls. Interview on 09/19/2023 at 7:17 p.m., RN N said he observed Resident #6 on hall 200 near his room in the hallway close to the nurse station. RN N said resident was sitting in his wheelchair bleeding from his nostrils with LVN and a CNA standing around resident. RN N said he was trying to stop the bleeding coming from resident nostrils which he was able to stop the bleeding. RN N said Resident #6 was not complaining of pain, but his words were not clear, and that resident spoke in allow tone. RN N said he did not notify the doctor. RN N said he assumed that the primary care nurse called the doctor and the RP. Resident CR #7 Record review of CR #7's face sheet revealed a [AGE] year-old female admitted to the NF on 12/08/2021 diagnoses that included the following: Alzheimer's Disease, nontraumatic subarachnoid hemorrhage from right middle cerebral artery, encephalopathy (brain disease that alters the brain function), dementia (loss of memory and judgement), insomnia (difficulty falling asleep), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), rheumatoid arthritis(Disorder affecting many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 17 of 35 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 09/25/2023 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 0684 joints including the hands and feet), and muscle weakness. Level of Harm - Immediate jeopardy to resident health or safety Record review of CR #7's x-ray of the spine cervical 2-3 views dated 02/27/2023 impression revealed: mild arthritis and loss of the normal cervical lordosis (condition that pushes the neck further forward than it should be or usually is). Residents Affected - Some Record review of CR #7's MDS dated [DATE] revealed that CR #7 had BIMS score of 5 indicating that CR #7's cognition was severely impaired. Further review revealed that CR #7 required supervision with bed mobility, transfer, eating, and toilet use. Further review revealed that CR #7 required limited assistance with dressing and personal hygiene. Record review of CR #7's Care Plan dated 12/15/2021 and revised 08/28/2023 revealed that resident was being care planned for falls and having an actual fall on 08/19/2023 and revised 08/28/2023 with an intervention that included the following: observe/document/report to MD as needed for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further record of CR #7's Care Plan did not reveal that CR #7 was being care planned for or loss of the normal cervical lordosis. Record review of CR #7's Nursing Progress Notes revealed in part: Documented by LVN G on 08/19/2023 at 6:28am .Resident noted lying on floor with blanket and pillow. When asked why she was on the floor, resident replied I am tired and want to sleep here .Resident educated to sleep in bed and not on floor. Resident assisted from floor to bed via staff .Resident resting quietly . Documented by LVN O on 08/19/2023 at 10:24 a.m., revealed in part: .Resident reported to this nurse that she fell on the floor during 10pm-6am shift. Resident is complaining of neck pain, bruises also noted on the left elbow. Resident also reported biting her tongue. NP in the building and notified . At 10:34 a.m. New order for X-ray left elbow, radius and humerus, left shoulder. X-ray called with the x-ray order . Documented by the DON dated 08/19/2023 at 10:52am revealed in part: .Resident was found sleep on the floor next to her bed .now she is complaining of pain .The NP at the facility give new order for place C-collar (cervical/neck brace) send to hospital for fall and c/o neck pain do not move pt/or stand . Documented by LVN O on 09/18/2023 at 12:20pm revealed in part: 911 call placed, EMS and transferred resident to the hospital .C collar in place . Record review of the NF Investigation report dated 08/19/2023 revealed that CR #7 was observed laying on floor, complained of pain, sent to the hospital and MRI revealed that that CR #7 had mildly displaced acute fractures of the anterior arch of C1 and C2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 18 of 35 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 09/25/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 09/14/2023 at 10:54 a.m., the hospital staff RNZZ said CR #7 was admitted to the hospital with a cervical fracture on 08/19/2023. RN ZZ said CR #7 was transferred to SICU and later to hospice services. RN ZZ said CR #7 passed away on 08/29/2023. Interview on 09/14/2023 at 12:20 p.m., the Administrator said CR #7 had a fall and was sent to the hospital. The Administrator said it was discovered at the hospital that CR #7 had a neck fracture. The Administrator said while CR #7 was at the hospital she developed pneumonia as well. The Administrator said CR #7 had been placed on in-patient hospice. Interview on 09/18/2023 at 11:23 a.m., LVN G said she worked on 08/19/2023 on the 10pm-6am shift. LVN G said when she arrived at work, CR #7 was sitting in her wheelchair at the front entrance and did not agree to go to bed until 3:00 a.m. LVN G said she made rounds on the residents around 5:00 a.m. and that CR #7 was resting in bed. LVN G said she made her last rounds on the residents at 6:00 a.m., and when she arrived at CR #7's room, CR #7 was on the floor on the left side of her bed wrapped in a blanket with a pillow resting under her head. LVN G said CR #7 said she wanted to lay on the floor. LVN G said she told CR #7 no and that she needed to get back in the bed. LVN G said she checked CR #7 for range of motion with no complaints of discomfort. LVN G said she called for help and that. LVN H with the assistance of the CNA, CR #7 was put back in bed. LVN G said she had been working at the NF for 3 years but practicing as a nurse for 7 months. LVN G said when a resident with confusion was found on the floor and no one know what happened, the course of action to take was to do range of motion assessing for pain. LVN G said she did not do a complete head to toe skin assessment before placing CR #7 back in bed. LVN G said she had been in- serviced on falls and that it was okay to move a resident with an unwitnessed fall after assessing their range of motion. LVN G said it was okay to move a resident that was conscious but not a resident that was unconscious. LVN G said she was not aware of the NF policy on un-witnessed falls. LVN G said she was just trying to keep CR #7 comfortable. LVN G said it was not normal behavior for CR #7 to lay on the floor. Interview on 09/18/2023 at 12:55 p.m., LVN O said she worked the weekend shift 6am-10pm and was the nurse that relieved LVN G on 08/19/2023. LVN O said she had received in report from LVN G letting her know that CR #7 was found on the floor with no injuries and that LVN G had initiated neuro checks. LVN O said when she arrived at CR #7 room, CR #7 was in bed and denied pain. LVN O said she continued the neuro checks per facility protocol and that when she returned to CR #7 room again, CR #7 was complaining of elbow pain. LVN O said she could not remember which elbow it was but noticed a little red bruise to the elbow. LVN O said at this time (could not remember the time), the NP was at the NF. LVN O said later, CR #7 started to complain of pain to her neck. LVN O said the NP assessed CR #7 asking resident to turn her neck, but CR #7 was unable to turn her neck. LVN O said the NP gave orders to place a C collar on resident neck and send to the hospital. Further interview on 09/18/2023 at 12:55 p.m., LVN O said she had been in- serviced on falls to check the resident status of orientation, if confused do not move the resident because resident may have injured themselves. LVN O said resident would be sent to the hospital for further evaluation. Interview on 09/18/2023 at 1:35 p.m., LVN H said she worked the night shift 10pm- 6am full time. LVN H said when CR #7 was found on floor in her room with pillow under head, she assisted LVN G along with the CNA in placing CR #7 back in bed. LVN H said CR #7 did not complain of pain. LVN G said the doctor and RP needed to be notified immediately about a fall witnessed or unwitnessed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 19 of 35 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 09/25/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Interview on 09/19/2023 at 11:10 a.m., CNA Q said she worked the 10pm-6am shift and was the CAN for CR #7. CNA Q said she was coming up the hallway around 5:45am-6:00am making her last rounds on the resident when she saw the nurse in CR #7 room. CNA Q said when she arrived at CR #7's room, CR #7 was on the floor with her bed in the. CNA Q said CR #7 was asked where she was going but CR #7 could not say. CNA Q said resident was not complaining of pain. CNA Q said right after she assisted with placing CR #7 back in bed, CR #7 began to complain of pain saying that her neck hurt. Residents Affected - Some Record review of the NF Policy on Falls revised September 2012 revealed in part: .The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls ( .increased risk of bleeding in someone taking an anticoagulant) . Record review of the NF Policy on Anticoagulation revised April 2007 revealed in part: The staff and physician will identify and address potential complications in individuals receiving anticoagulation; for example, someone with a fall risk . The Administrator and DON was notified on 09/14/2023 at 1:56 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on 09/14/2023 at 1:56 P.M. and a Plan or Removal (POR) was requested. The facility POR was accepted on 09/15/2023 at 10:14a.m. and indicated: PLAN OF REMOVAL

F684 Name of facility: Park Manor Cypress Station Date: 09/14/2023 Immediate Action Impact Statement: On 9/14/23 an abbreviated survey was initiated at Park Manor of Cypress Station at 420 Lantern Bend Dr, Houston, Texas 77090. On 9/14/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to ensure that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and resident choice. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all falls in residents on blood thinners in the last 30 days to ensure the residents received treatment and care in accordance with professional standard of practice. All residents on blood thinners that had a fall have the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to hospital on 9/11/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 20 of 35 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 09/25/2023 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 0684 Nurse on duty received 1:1 in-service on falls in residents receiving anticoagulant medications. Level of Harm - Immediate jeopardy to resident health or safety What corrective actions were taken? Residents Affected - Some The following actions were initiated immediately on 9/14/23 1. a. On 9/14/23 an audit was completed by CSD (Clinical Services Director) and/or designee to identify all residents on anticoagulants who had a fall in the last 30 days to ensure these residents received treatment and care in accordance with professional standard of practice. No residents were identified to be affected by deficient practice. b. Director of Nursing was educated on 9/14/23 by Clinical Services Director on process of care for residents on anticoagulants when experience a fall with head injury are sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse. a) Initiated in-services on 9/14/23 with licensed nurses by Director of Nursing /Designee to send residents that are on anticoagulant medications and sustain a head injury to a higher level of care for further evaluation care via 911 based on resident assessment by licensed nurse. Completed by 9/15/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed. 2. How will the system be monitored to ensure compliance? b) The Director of Nurses/Administrator will review falls in morning meeting starting on 9/15/23 and ongoing to ensure falls on residents taking anticoagulant medications are appropriately addressed. Any identified concerns will be addressed immediately, and additional training will be provided as needed. c) The weekend supervisor and/or designee was in-serviced on 9/14/23 by Director of Nursing/ Designee on identifying all residents experiencing falls on Saturdays and Sundays and ensure that any resident on anticoagulant medication that experiences a fall with head injury are sent to a higher level of care via 911 based on resident assessment by licensed nurse. d) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 21 of 35 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 09/25/2023 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Newly hired staff and PRN staff will be educated by the Director of Nursing/Designee on residents taking blood thinners that sustain a head injury are sent to a higher level of care for further evaluation care via 911 based on resident assessment by licensed nurse. Completed by 9/15/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed. Quality Assurance Residents Affected - Some An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 9/14/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan that includes the Fall Policy updated with residents on anticoagulant medications will be send via 911 transport based on license nurse assessment. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 09/15/2023 at 12:11 p.m., LVN C who worked the morning shift 6am-2p.m. said she received in-service on falls with head injuries. LVN C said if a resident had a fall with head injuries, she was to call 911 to transport resident to the hospital to be further evaluated. Interview on 09/15/2023 at 12:14 p.m., LVN B who worked the morning shift 6am-p.m. said she had been in-serviced on the following: fall precautions and the new protocol that if resident had a fall with head injuries and on blood thinners, the resident had to be sent to a higher level of care to be further evaluated. LVN B said if the resident denied pain after the fall to continue doing neuro checks per NF protocol. LVN B said if the resident began to show a change in condition with the neuro checks, she was to call the physician and the RP. Interview on 09/15/2023 at 12:22 p.m., LVN D said she worked the morning shift 6am-2pl time. LVN D said she had been in-serviced on that when a resident experience a fall with head injuries and on blood thinners, she had to send resident to the hospital via 911 services. Interview on 09/15/2023 at 4:52 p.m., LVN E said she worked the 2pm-10pm shift full time Monday through Friday. LVN E said she had been in-serviced on falls. LVN E said if a resident fell with head injuries and was taking blood thinners, that resident had to be sent to the hospital via 911 services. Interview on 09/15/2023 at 4:55 p.m., RN F said she worked the 2pm-10pm shift full time. RN F said she had been in-serviced on falls. RN F said if a resident had fallen and hit their head and was taking blood thinners, the resident had to be transported to the hospital via 911 services[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 22 of 35 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 09/25/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 2 of 11 residents (Resident #6 and CR #7) reviewed for accidents in that: -The facility failed to implement Resident #6 care plan to monitor resident to prevent fall from wheelchair developing a right frontal contusion and displaced fracture of the right frontal calvarium (section of the skull). -The facility failed to take proper precautions when CR #7 who x-ray results revealed loss of normal cervical lordosis (improper alignment of the neck) experienced an unwitnessed fall. CR #7 had a fractured C1 & C2 (neck region). An IJ was identified on 09/21/2023. While the IJ was removed on 09/25/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place other residents in the NF with unwitnessed falls with injuries at risk for unwanted hospitalization and death. Findings: Resident #6 Record review of Resident #6 face sheet revealed an 86year old male admitted to the NF on 05/01/2019 with the following diagnoses that included: nontraumatic subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain-08/25/2023), cerebral infarction (disruption of blood flow to the brain, Parkinson's Disease (disorder that effects movement), contracture (shortening and hardening of the muscles), history of falling, heart failure, hypertension (high blood pressure), hypotension (low blood pressure), dementia (impairment of the brain causing memory loss and judgement), and metabolic encephalopathy (disorder of the brain caused by a chemical imbalance in the blood). Record review of Resident #6 MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition level was severely impaired. Further review revealed that Resident #6 required extensive assistance with bed mobility, transfer, dressing, eating, and total assistance with toileting and personal hygiene. Record review of Resident #6 Care Plan revealed that resident was being care planned for falls related to poor balance dated 07/04/2023 with an intervention that included keep resident on visible area for close monitor. Record review of Resident #6 Nursing Progress Notes dated 08/19/2023 documented by LVN M at 5:21pm revealed in part: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 23 of 35 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 09/25/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety .Resident observed on the floor at the top of the 200 hallway. He is observed face down on the floor, in front of his wheelchair. He was assessed for injuries and pain, then assisted back into his wheelchair x 3 staff. He is noted with a small amount of running, bright red blood coming out of his nose, nose pinched together for a few seconds, bleeding stopped, no visible injuries noted. Family member arrived shortly afterward and were informed of the incident and requested an ice pack to apply to his nose. A few minutes later, family member requested would like for resident be transported to the hospital to have a CT SCAN. Regular EMS Residents Affected - Few phoned to transport resident to hospital .5:53pm regular transportation here to transport resident to the hospital per family request . Record review of Resident #6 hospital records dated 08/19/2023 that a CT of the head was done with the following impression: right frontal contusion (injured skin or tissue where blood vessels have burst suddenly) .small volume subarachnoid hemorrhage . Record review of the NF investigation report revealed that Resident #6 CT scan at the hospital showed that resident had a displaced fracture in the right frontal calvarium (skull) with extension into the right orbital (bony space that contains the eyeball) roof. Interview on 09/19/2023 at 1:27pm RP of Resident #6 said she did not receive a call from the NF regarding resident fall. The RP said when she arrived at the NF, resident had redness, bruising, and swelling to the side of his eye, could not remember which eye it was. The RP said she had to request that Resident #6 be sent out to the hospital. The RP said it took the NF about 30 minutes to transport resident to the hospital. Interview on 09/19/2023 at 2:32pm LVN M said she worked at the NF on weekends part time 6am-6pm shift. LVM M said on 08/19/2023 she was called by RN N telling her that Resident #6 was on the floor and that resident had been placed back in his wheelchair. LVN M said when she saw resident, he was sitting in his wheelchair with blood on the side of his nose as well as on the outside of his nose. LVN M said she pinched resident nostrils and cleaned it with a wet towel and the bleeding stopped. LVN M said she assessed resident for injuries and initiated neuro checks on resident. LVN M said she called the RP and the doctor. LVN M said the RP wanted to send resident out to the hospital. LVN M told the surveyor what all took place around Resident #6 fall on 08/19/2023 was documented in the nurse's notes. LVN M said the last time she received in-service on falls was last week but could not remember the last time she received in- services on unwitnessed falls. Interview on 09/19/2023 at 7:17pm RN N said he observed Resident #6 on hall 200 near his room in the hallway close to the nurse station. RN N said resident was sitting in his wheelchair bleeding from his nostrils with LVN and a CNA standing around resident. RN N said he was trying to stop the bleeding coming from resident nostrils which he was able to stop the bleeding. RN N said Resident #6 was not complaining of pain, but his words were not clear, and that resident spoke in allow tone. RN N said he did not notify the doctor. RN N said he assumed that the primary care nurse called the doctor and the RP. Resident CR #7 Record review of CR #7 face sheet revealed a 73year old female admitted to the NF on 12/08/2021 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 24 of 35 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 09/25/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few diagnoses that included the following: Alzheimer's Disease, nontraumatic subarachnoid hemorrhage from right middle cerebral artery, encephalopathy (brain disease that alters the brain function), dementia (loss of memory and judgement), insomnia (difficulty falling asleep), hypertension (high blood pressure), atrial fibrillation (irregular heart beat), rheumatoid arthritis (disorder affecting many joints including the hands and feet), and muscle weakness. Record review of CR #7's x-ray of the spine cervical 2-3 views dated 02/27/2023 impression revealed: mild arthritis and loss of the normal cervical lordosis (condition that pushes the neck further forward than it should be or usually is). Record review of CR #7's MDS dated [DATE] revealed that CR #7 had BIMS score of 5 indicating that CR #7 cognition was severely impaired. Further review revealed that CR #7 required supervision with bed mobility, transfer, eating, and toilet use. Further review revealed that CR #7 required limited assistance with dressing and personal hygiene. Record review of CR #7 Care Plan dated 12/15/2021 and revised 08/28/2023 revealed that resident was being care planned for falls and having an actual fall on 08/19/2023 and revised 08/28/2023 with an intervention that included the following: observe/document/report to MD as needed for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further record of CR #7's Care Plan did not reveal that CR #7 was being care planned for or loss of the normal cervical lordosis. Record review of CR #7's Nursing Progress Notes revealed in part: Documented by LVN G on 08/19/2023 at 6:28am .Resident noted lying on floor with blanket and pillow. When sked why she was on the floor, resident replied I am tired and want to sleep here .Resident educated to sleep in bed and not on floor. Resident assisted from floor to bed via staff .Resident resting quietly . Documented by LVN O on 08/19/2023 at 10:24am revealed in part: .Resident reported to this nurse that she fell on the floor during 10pm-6am shift. Resident is complaining of neck pain, bruises also noted on the left elbow. Resident also reported biting her tongue. NP in the building and notified . At 10:34am New order for X-ray left elbow, radius, and humerus, left shoulder. X-ray called with the x-ray order . Documented by the DON dated 08/19/2023 at 10:52am revealed in part: .Resident was found sleep on the floor next to her bed .now she is complaining of pain .The NP at the facility give new order for place C-collar (cervical/neck brace) send to hospital for fall and c/o neck pain do not move pt/or stand . Documented by LVN O on 09/18/2023 at 12:20pm revealed in part: 911 call placed, EMS and transferred resident to the hospital .C collar in place . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 25 of 35 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 09/25/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of the NF Investigation report dated 08/19/2023 revealed that CR #7 was observed laying on floor, complained of pain, sent to the hospital and MRI revealed that that CR #7 had mildly displaced acute fractures of the anterior arch of C1 and C2. Interview on 09/14/2023 at 10:54am the hospital staff RN-ZZ said CR #7 was admitted to the hospital with a cervical fracture on 08/19/2023. RN ZZ said CR #7 was transferred to SICU and later to hospice services. RN ZZ said CR #7 passed away on 08/29/2023. Interview on 09/14/2023 at 12:20pm Administrator said CR #7 had a fall and was sent to the hospital. The Administrator said it was discovered at the hospital that CR #7 had a neck fracture. The Administrator said while CR #7 was at the hospital she developed pneumonia as well. The Administrator said CR #7 had been placed on in-patient hospice Interview on 09/18/2023 at 11:23am LVN G said she worked on 08/19/2023 on the 10pm-6am shift. LVN G said when she arrived at work, CR #7 was sitting in her wheelchair at the front entrance and did not agree to go to bed until 3:00am. LVN G said she made rounds on the residents around 5:00am and that CR #7 was resting in bed. LVN G said she made her last rounds on the residents at 6:00am and went she arrived at CR #7's room, CR #7 was on the floor on the left side of her bed wrapped in a blanket with a pillow resting under her head. LVN G said CR #7 said she wanted to lay on the floor. LVN G said she told CR #7 no and that she needed to get back in the bed. LVN G said she checked CR #7 for range of motion with no complaints of discomfort. LVN G said she called for help and that LVN H with the assistance of the CNA, CR #7 was put back in bed. LVN G said she had been working at the NF for 3 years but practicing as a nurse for 7 months. LVN G said when a resident with confusion was found on the floor and no one know what happened, the course of action to take was to do range of motion assessing for pain. LVN G said she did not do a complete head to toe skin assessment before placing CR #7 back in bed. LVN G said she had been in- serviced on falls and that it was okay to move a resident with an unwitnessed fall after assessing their range of motion. LVN G said it was okay to move a resident that was conscious but not a resident that was unconscious. LVN G said she was not aware of the NF policy on un-witnessed falls. LVN G said she was just trying to keep CR #7 comfortable. LVN G said it was not normal behavior for CR #7 to lay on the floor. Interview on 09/18/2023 at 12:55pm LVN O said she worked the weekend shift 6am-10pm and was the nurse that relieved LVN G on 08/19/2023. LVN O said she had received in report from LVN G letting her know that CR #7 was found on the floor with no injuries and that LVN G had initiated neuro checks. LVN O said when she arrived at CR #7 room, CR #7 was in bed and denied pain. LVN O said she continued the neuro checks per facility protocol and that when she returned to CR #7 room again, CR #7 was complaining of elbow pain. LVN O said she could not remember which elbow it was but noticed a little red bruise to the elbow. LVN O said at this time (could not remember the time), the NP was at the NF. LVN O said later, CR #7 started to complain of pain to her neck. LVN O said the NP assessed CR #7 asking resident to turn her neck, but CR #7 was unable to turn her neck. LVN O said the NP gave orders to place a C collar on resident neck and send to the hospital. Further interview on 09/18/2023 at 12:55pm with LVN O said she had been in- serviced on falls to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 26 of 35 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 09/25/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few check the resident status of orientation, if confused do not move the resident because resident may have injured themselves. LVN O said resident would be sent to the hospital for further evaluation. Interview on 09/18/2023 at 1:35pm LVN H said she worked the night shift 10pm- 6am full time. LVN H said when CR #7 was found on floor in her room with pillow under head, she assisted LVN G along with the CNA in placing CR #7 back in bed. LVN H said CR #7 did not complain of pain. LVN G said the doctor and RP needed to be notified immediately about a fall witnessed or unwitnessed. Interview on 09/19/2023 at 11:10am CNA Q said she worked the 10pm-6am shift and was the CAN for CR #7. CNA Q said she was coming up the hallway around 5:45am-6:00am making her last rounds on the resident when she saw the nurse in CR #7 room. CNA Q said when she arrived at CR #7's room, CR #7 was on the floor with her bed in the. CNA Q said CR #7 was asked where she was going but CR #7 could not say. CNA Q said resident was not complaining of pain. CNA Q said right after she assisted with placing CR #7 back in bed, CR #7 began to complain of pain saying that her neck hurt. Record review of the NF Policy on Quality of Care: Safety and Supervision of Residents revised December 2007 revealed in part: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety . The * Administrator was notified on 09/21/00 at 3:04 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failure. The *Administrator was provided the IJ template on 09/21/23 at 3:04 PM and a Plan or Removal (POR) was requested. The facility POR was accepted on 09/23/20 at 3:00 PM and indicated: PLAN OF REMOVAL

F689 Name of facility: Park Manor Cypress Station Date: 09/23/2023 Immediate Action Impact Statement: On 9/21/23 the state surveyor entered to continue an abbreviated survey at Park Manor of Cypress Station at 420 Lantern Bend Dr, Houston, Texas 77090. On 9/21/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure of the facility of developing and implementing a system ensuring that all nursing staff are in-serviced/trained on the importance of sending a resident to a higher level of care that experience an unwitnessed fall with head injuries via 911. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all unwitnessed falls in residents with head injury in the last 30 days to ensure the residents received treatment and care in accordance with professional standard of practice. All residents with unwitnessed falls have the potential to be affected by this deficient practice, no other residents were identified as being affected. Audit completed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 27 of 35 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 09/25/2023 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 0689 9/21/2023 by Director of Nursing. Level of Harm - Immediate jeopardy to resident health or safety What corrective actions have been implemented for the identified resident? Residents Affected - Few Resident #6 readmitted to facility and is in stable condition. Resident's care plan was updated with fall incident and interventions to prevent further falls. Staff were educated on resident's updated plan of care for fall. Resident CR # 7 was discharged to hospital on 8/19/2023. Nurses on duty for the above residents received 1:1 in-service by Director of Nursing on unwitnessed fall protocol that included the assessment of resident and following the Care Path Fall Tool attached. CNAs were in-serviced by Director of Nursing on fall protocol that included not to move a resident post fall and to immediately notify the license nurse to assess resident. What corrective actions were taken? 5. The following actions were initiated immediately on 9/21/23. f. On 9/21/23 an audit was completed by the Director of Nursing and/or designee to identify all unwitnessed falls in the last 30 days to ensure these residents received treatment and care in accordance with professional standard of practice. No residents were identified to be affected by deficient practice. Residents with falls in the last 30 days had their care plan for fall reviewed for interventions and effectiveness by Director of Nursing/designee on 9/21/2023. g. Director of Nursing was educated on 9/21/23 by Clinical Services Director on the protocol of unwitnessed fall with major/serious injury being sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. h. Initiated in-services on 9/21/23 with licensed nurses by Director of Nursing /Designee on protocol of unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until in-service is completed on protocol of unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 28 of 35 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 09/25/2023 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 0689 6. Level of Harm - Immediate jeopardy to resident health or safety How will the system be monitored to ensure compliance? Residents Affected - Few The Director of Nurses/Administrator will review falls in morning meeting starting on 9/22/23 and ongoing to ensure unwitnessed falls with/or suspected major/serious injury are appropriately addressed. Any identified concerns will be addressed immediately, and additional training will be provided as needed. a. b. The weekend supervisor and/or designee was in-serviced on 9/21/23 by Director of Nursing/ Designee on identifying all residents experiencing falls on Saturdays and Sundays to ensure that any resident that experiences an unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. c. Newly hired staff and PRN staff will be educated by the Director of Nursing/Designee to send residents that experience an unwitnessed fall with/or suspected major/serious injury to a higher level of care for further evaluation care via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed on protocol for unwitnessed falls with/or suspected major/serious injury. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 9/21/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan that includes the Fall Policy updated on neglect policy and fall protocol including unwitnessed falls with/or without injuries. Unwitnessed falls will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 09/24/2023 at 11:36am RN P said she worked the 6am-6pm shift and had been in-serviced on abuse and neglect, falls unwitnessed or witnessed and the resident on anticoagulants that experienced injury especially head injury to send resident out to the hospital via 911 services. Interview on 09/24/2023 at 11:42am LVN RR said she worked at the NF PRN on the 6am2pm shift. LVN RR said she had been in-serviced on abuse and neglect, falls assessing residents with witnessed and un-witnessed falls. LVN RR said after assessing the resident and there are complaints of pain do not move the resident, check to see if the resident is on any blood thinners, send to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 29 of 35 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 09/25/2023 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 0689 the hospital via 911 for further evaluation, notifying the doctor and the RP. Level of Harm - Immediate jeopardy to resident health or safety Interview on 09/24/2023 at 11:50am LVN R said she worked at the NF full time 8am-5pm. LVN RR said she had been in-serviced on falls witnessed and unwitnessed to do a head-to-toe assessing for pain or any injuries. LVN R said if the resident hit their head neuro checks had to be initiated per facility protocol. LVN RR said she was in-serviced to check to see if the resident was on any blood thinners and prepare to send the resident to the hospital 911. LVN RR said if an injury is suspected, do not move the resident, and send to hospital 911 for further evaluation being sure to notify the doctor and RP and document all actions taken. Residents Affected - Few Interview on 09/24/23 at 12:00pm CNA S said she worked at the NF full time on the weekends 6am-10pm and had been in-serviced on falls. CNA S said if a resident had fall that was witnessed or un-witnessed do not move the resident and get the nurse right away to assess the resident. Interview on 09/24/2023 at 12:05pm CNA V said she worked the 6am-2pm shift and had been in-serviced on abuse and neglect, falls, not to move the resident but alert the nurse so that the resident could be assessed for any injuries. Interview on 09/24/2023 at 12:08pm CNA K said she worked the 6am-2pm shift on certain days and the 2pm-10pm shift on certain days. CNA K said she had been in-serviced on abuse and neglect, falls, and the prevention of falls (keeping the resident call light in reach). CNA K said if a resident had a fall, she was not to move the resident instead stay with the resident and call for the nurse. CNA K said she had also been in-serviced on going into the computer to look at the resident POC to see what interventions had been put in place to care for the resident needs and follow the interventions. Interview on 09/24/2023 at 12:17pm CNA U said she worked the 6am-2pm and had been in- serviced on that when a resident fall to stay with the resident and call the nurse. CNA U said she had also been in-serviced on abuse and neglect. Interview on 09/24/2023 at 1:05pm CNA X said she worked the 2pm-10pm shift. CNA X said she had been in-serviced on falls and fall risk, keeping the resident's bed in low position, call lights in reach, fall matts on the floor at the bed side. CNA X said if she witnessed a fall or unwitnessed a fall, she was not to move the resident but stay with the resident and call the nurse right away. Interview on 09/24/2023 at 1:33pm CNA I said she worked various shifts pending where the staffing needs were. CNA I said she had been in-serviced on falls witnessed and unwitnessed not to move the resident, stay with the resident and alert the nurse. CNA I said she was also in-serviced that if she was not familiar with the resident care needs, she could look at the resident POC in the computer. Interview on 09/24/2023 at 8:10pm RN A (worked 6pm-6am) said he had been further in- service on falls to assess the resident for injuries and if so, do not to move the resident and call 911 to send the resident out to the hospital right away to be evaluated. Interview on 09/24/2023 at 8:20pm RN F said she worked the 2pm-10pm shift and had been in-serviced on abuse and neglect as well as falls. RN F said she had been further in-serviced on falls that if there were injuries or suspected injuries to not move the resident and call 911 to have resident sent out to the hospital 911. Interview on 09/24/2023 at 8:27pm CNA Y via phone said she worked the 10pm-6am shift and had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 30 of 35 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 09/25/2023 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 0689 in-serviced on abuse and neglect and falls to not move the resident and call the nurse. Level of Harm - Immediate jeopardy to resident health or safety Interview on 09/25/2023 at 10:30am LPN Z said she worked the 6am-2pm shift and sometimes the 2pm-10pm shift. LPN Z said she had been in-serviced on falls witnessed and un- witnessed. LPN Z said she had also been in-service on how to look on the computer to review the resident (s) plan of care and their interventions. LPN Z said if a resident had a fall, she would assess the resident for injuries, review the resident medications to see if they were on any blood thinners; LPN Z said if the resident had injuries or suspected injuries, she was in- serviced not to move the resident, call 911 to have resident transported to the hospital right away for further evaluation. LPN Z said she had also been in-serviced on abuse and neglect. Residents Affected - Few Interview on 09/25/2023 at 10:36am LVN C said she had been further in-serviced on falls witnessed or unwitnessed assess range of motion. LVN c said if the resident complained of pain, do not move the resident, and arrange to have resident sent to the hospital via 911. Interview on 09/25/2023 at 10:42pm CNA AA said she worked the 6am-2pm shift and that she had received in-service on residents falling and to not leave the resident alone and call the nurse. CNA AA said she had also received in-services on abuse and neglect. Interview on 09/25/2023 at 10:47am CNA CC said she worked the 6am-2pm shift and had been in-serviced on abuse and neglect, falls witnessed and unwitnessed to not move the resident but stay with the resident and call the nurse. Interview on 09/25/2023 at 10:54am CNA DD said she worked the 6am-2pm shift and that she had been in-serviced on fall preventions, keeping the bed in the low locked position with the call light in reach. CNA DD said she had also been in-serviced that if a resident fell, to stay with the resident, don't move the resident and call the nurse. Interview on 09/25/2023 at 11:16am via phone LVN BB said she worked the 6pm-6am shift. LVN BB said she had been in-serviced on falls witnessed and un-witnessed. LVN BB said if the resident had fallen and was alert and oriented able to tell what happened and hit his head, she would not move the resident, checked to see if the resident was on any blood thinners, initiate neuro checks, call the physician and the RP, and prepare to send the resident to the hospital via 911. LVN BB said she had also been in-serviced on abuse and neglect and who to report it to which was the Administrator. Interview on 09/25/2023 at 11:30am CNA FF via phone said she worked the 10pm-6am shift. CNA FF she had been in-serviced on abuse and neglect and to report to the Administrator. CNA FF said she was in-serviced on falls when a resident had a fall to not move the resident and call foe the nurse. CNA FF said she had been in-serviced on fall preventions by keeping the resident bed in a low position with call light in reach. On 09/25/2023 at 12:26 p.m., the Administrator, Clinical Service Director was informed that the IJ was removed, however, the facility remained out of compliance at a scope of a isolated and severity of actual harm that is not IJ as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 31 of 35 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 09/25/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 provide food that was palatable, and at a safe and appetizing temperature for 3 of 5 residents reviewed for food temperature. Residents Affected - Some The facility failed to provide food that was palatable for 3 of 4 (R#2 #3,#4) residents served (Regular,) at 2 of the 3 meals observed. The facility failed to have sufficient staff to deliver meals to the resident rooms in the required time frame. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Electronic Record Review of Resident #2 face sheet dated 7.27.21, revealed an [AGE] year-old admitted to the facility on [DATE] with a primary diagnosis revealed unspecified dementia (unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record Review of Resident #2 Annual MDS dated 8.4.23 (BIMS -11) revealed a BIMS (Moderately Impaired Cognition) score of 11. Record Review of Resident #4 face sheet reveal she was admitted [DATE] and readmitted [DATE]. Record Review of Annual MDS dated 8.2.23 revealed a BIM score of 15 (Cognitive Intactness). Record Review of Resident #3 face sheet dated 5.31.22 Record Review of Resident #3's Annual MDS dated 6.9.23 revealed BIM Score of 5 (Severe Cognitive Impairment). Observations revealed the facility's mealtime posting, which is visible on the nurse's station located in the entrance areas for all visitors and residents to see, Breakfast at 7am; Lunch at 12:00PM and Dinner at 5PM. There are 4 resident hallway living areas. The postings in each hallway, 100, 200, 300 and 400 revealed, Mealtimes, Breakfast at 7:10am, Lunch at 12:10pm, and Dinner at 5:10PM. Observation on 9/13/2023 at 12:24 p.m., the Dining Tray delivered to conference room for staff. The menu was meat loaf, potatoes and gravy and carrots. The meat loaf's temp was taken using the Investigator's temperature gauge and it was 70 degrees, potatoes were a little warm and cooked carrots were cool to the taste. Observation on 9/14/23 at 7:10AM,. some residents were seated in the dining area, while staff was entering with other residents. At 7:25am, an intercom message for all staff to assist with residents in the dining room. At this time, a kitchen employee emerged from the kitchen area with the tray stands with trays. The DON was assisting with placing trays on the tables where residents were seated. There were another staff person doing the same. Observation on 9/14/23 at 7:30AM, observed trays on the 100-resident hallway corridor. The administrator along with another employee were passing the trays out to the rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 32 of 35 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 09/25/2023 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on 9/14/23 At 7:50AM, Resident #3 was not eating her Oatmeal, Eggs & Toast. She stated the entire meal was cold and she could not eat it. She stated the Kitchen area is nasty. Stated by time you send your plate back to the kitchen when the staff return its almost the next feeding schedule. She stated sometimes she just has to accept what she gets since this facility is her only option. Observation on 9/14/23 at 7:57AM, this surveyor observed trays still on the cart in the 400- hallway corridor to be passed out. The Administrator arrived and began passing trays to residents who were in their room waiting for their breakfast meal. Observation and interview on 9/14/23 at 8:00AM, Resident #4 lifted the cover from the top of her plate. She had just received her tray. Resident #4 was served Grits and Coffee, this surveyor observed both, the grits and coffee, to be cold, which was confirmed by the resident. Resident #4 put a piece of butter on the grits, and it did not melt. This surveyor felt the outside of the coffee cup and it was not warm. Resident #4 said, this is the norm most times, but there is nothing you can do. The resident stated complaining does not help and complaints just goes on death ears. Observation on 9/14/23 at 12:00PM of the kitchen area, the dietary manager was asked to test the food on the serving table. The initial test revealed the following: Lasagna 192.9 degrees Green beans 181 degrees Puree green beans 145 degrees Mash potatoes 120 degrees Gravy 134 degrees Potato salad 44.4 degrees Puree bread 92.7 The dietary manager was asked to ensure the gravy was at the correct temperature along with the lasagna and green beans. The second test revealed the following: Lasagna at 145 Green Beans 145 Mash Potatoes at 130 Puree at 140 (green Beans) The dietary manager was asked a third time to address the food temperature for the Mashed Potatoes, which she did, and the final temperature was 150 degrees. The Dietary Manager revealed if the food on the stream table was at least 135 degree it was acceptable. She was asked to produce the dining/nutrition policy. The noon meal was served in the dining room at approximately 12:44PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 33 of 35 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 09/25/2023 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on 9/14/23 at 12:46PM, the Dietary Manager delivered the test tray as requested, the tray had Lasagna, drinks and salad was served. [NAME] Beans were not on the tray and when asked, the dietary manager indicated the green beans was for residents with a special diet. The dietary manager was asked to observe as this surveyor tested the temperature of the lasagna with thermometer. this surveyor asked the dietary manager what the results of the food temperature revealed, and she responded, 100 degrees. The dietary manager reiterated the food on the steam table is supposed to be at least 135. She further stated it (Lasagna) drops temps when you cut into it. This surveyor asked if each resident should have food that is warm like everyone else. She stated she don't know anything about that, she just knows that food temperature drops when it is cut and leave the serving line. She states the dining room is fed first and then the residents in their room are fed. When asked if she feels it is right for the people in their rooms to receive often cold food, she refused to answer. Dietary Manager stated she did not know what the policy said about the food temperature. Observation on 9/17/2023 at 12:10PM, this surveyor observed dining room residents' meal beginning to be served. There are 4 hallways with residents who eat in their rooms. The 300-hallway had the first cart of trays delivered at 12:37PM. 100-hallway had the tray cart delivered at 12:40pm. The 400-hallway tray cart was delivered at 1:00PM. Lastly, the 200-hallway tray cart was delivered at 1:05PM. The cart is placed in the front of the hallway for staff to take plates off and deliver it to the resident's room. Observation on 9/18/23 at 12:40PM, 100 Resident Hall trays delivered 12:38PM; 400 Resident Hall trays delivered at 12: 40PM; 300 Resident Hall trays delivered 12:42PM; 200 Resident Hall trays delivered at 12:51pm. Observation revealed the facility's mealtime posting, which is visible on the nurse's station located in the entrance areas for all visitors and residents to see, Breakfast at 7am; Lunch at 12:00PM and Dinner at 5PM. There are 4 resident hallway living areas. The postings in each hallway, 100, 200, 300 and 400 revealed, Mealtimes, Breakfast at 7:10am, Lunch at 12:10pm, and Dinner at 5:10PM. Interview on 9/13/2023 at 10:50AM, Resident #2- Stated he has been at the facility for 2 years. Resident states she has complained about her Food. She says her cold food is served warm and warm food is served cold. She states she does not eat in the dining area. She said the staff leaves the tray at the end of the hallway and by time they serve me the food it is not at an adequate temperature. She states the workers are not wearing, gloves or hairnets. Resident #2 states in the morning her coffee is cold, and they don't give her sugar or cream, the grits are cold and there is no butter. She says she has made several unsuccessful attempts to call ombudsman office. She's left messages and no one responds. Interview on 9/14/23 at 1:05 PM, the DON stated that there have been complaints/grievances from residents regarding the temperature of the food. She stated the residents who eat in their rooms are fed after the dining room residents. She stated all the residents should have food that has an adequate temperature. She stated if a resident's food is not warm enough, they can ask staff (CNA) to return their plate to kitchen, then the food is warmed up by microwave and brought back to them. The DON was unable to say how long this process would take. Interview on 9/17/2023 at 1:18 PM, CNA A stated she has been working here at the facility for almost a year. She states she is a staffing coordinator, and she coordinates the CNA's schedule for supervision in each hallway. She states there are times when residents complain about their food not being warm enough. She states that whenever a tray is delivered to A room and the patient or resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 34 of 35 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 09/25/2023 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some does not like the food temperature then the staff returned the tray immediately and having warmed up and take him back to the patient for their approval. She states missus manner is sometimes difficult however she is a resident and staff will accommodate her. She states miss manner refuses showers which is documented by the CNA's. Interview on 9/18/2023 at 11:15AM, the Dietary Manager stated the residents eat 7:00am, 12:00pm and 5:00pm. She stated there are schedules posted in the hallways for the residents who eat in their rooms. Those posted times are 7:10am. 12:10pm and 5:10pm. She stated she and the Administrator was discussing the issues regarding trays getting residents who are eating in their rooms. She states there is a feeding time of 1 1/2hours for all residents. When asked for the documentation in policy, she stated there is no documentation or policy to support the feeding timeline. Interview on 9/18/2023 at 11:32AM, the Dietary District Manager, stated he is contracted through the facility. Therefore, he nor the dietary manager is directly employed by the facility. Dietary District Manager stated the contracted He states the dietary department is contracted through his company. Dietary District Manager states the times for resident feeding are 7am, 12, and 5pm. States the facility in conjunction with the healthcare services group agree on the time; however, the ultimate decision for the feeding schedule is up to the facility. Dietary District Manager stated Dietary is ready at the posted times but must wait for facility staff members assigned to specific hallways to come into the dining areas to assist with placing trays on the table. Some of the staff are also required to feed the residents. He states if there is a waiting period it's because there isn't enough staff in the dining area, which is based on facility management and not dietary services. Interview on 9/18/2023 at 12:52PM, CNA J said she works 400-hall. She stated sometimes she gets complaints from residents because food is cold. She stated the afternoon trays are typically delivered between 1:00pm -1:15pm. Record Review revealed of the Resident Nutrition Services policy (Revised 9/2017). According to the policy, #5 states, To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41F to 135F) will be kept to a minimum. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 35 of 35