Health inspection·May 9, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 5/7/24 at 1:27 p.m. the Administrator said patches should be disposed of in the trash can because of infection control. He said he did not know why the patches were on the floor and nurses were responsible for ensuring they were in the trash. Record review of the facility's Administering Medications policy dated December 2012 read in part, . Medications shall be administered in a safe and timely manner, and as prescribed . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 2 of 9 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 05/09/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #32) reviewed for significant medication errors. Residents Affected - Few -MA N attempted to administer Eliquis 5 mg (a blood thinner) to Resident #32 instead of Eliquis 2.5 mg according to Physician orders. Surveyor intervened. This failure could result in increased side effects and hospitalization. Findings include: Record review of Resident #32's face sheet dated 5/9/24 revealed a [AGE] year-old male who readmitted on [DATE]. His diagnosis included Alzheimer's disease, heart failure, peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs), and cognitive communication deficit. Record review of Resident #32's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. He required supervision or touching assistance with ADL care. Record review of Resident #32's care plan dated 1/23/24 revealed he was on anticoagulant therapy related to peripheral vascular disease. His interventions were to administer medication as ordered. Record review of Resident #32's Physician Orders revealed an order for Apixaban 2.5 mg give 1 tablet two times a day for prophylactic, order date 5/8/24. Record review of Resident #32's MAR for May 2024 revealed Apixaban 2.5 mg 1 tablet by mouth two times a day for prophylactic was scheduled for 8:00 a.m. and 4:00 p.m. In an Observation and Interview on 5/8/24 at 8:33 a.m. of Resident #32's morning medication pass with MA N revealed she prepared Eliquis (Apixaban) 5 mg (whole tablet), Midodrine 10 mg, and Pantoprazole 40 mg for Resident #32. She locked the medication cart and entered the resident's room. As she prepared to administer the medication to Resident #32 this Surveyor intervened. This Surveyor asked MA N to retrieve the Eliquis (Apixaban) blister pack from the cart. MA N retrieved Eliquis 5 mg (whole tablet) again. She said Oh and then said she did not have Eliquis 2.5 mg on the cart. MA N cut the 5 mg pill in half. MA N said she previously asked another nurse about cutting the pill but then said she would ask the DON. MA N asked the DON for Eliquis 2.5 mg and the DON said she would retrieve it from the emergency pharmacy kit. MA N said when she passed medications she verified the medication name, strength, and resident's name to the system. She said she thought she saw 5 mg on the MAR and was used to the resident receiving the 5 mg. She said Eliquis was a blood thinner and if he received more than prescribed his blood would be thinner than normal and he could die. Interview on 5/9/24 at 11:51 a.m. the DON said it was important for nursing staff to follow physician orders and verify the right medication, dose, time, and protocol for medication pass. She said Eliquis was for DVT (deep vein thrombosis, a condition in which the blood clots form in veins located deep inside the body) and Resident #32 was previously on 5 mg, but it was changed to 2.5 mg twice per day because he was bleeding. She said if he received more Eliquis than prescribed he could have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 3 of 9 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 05/09/2024 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bleeding and bruises. She said the Unit Manager, DON, charge nurse, and the person passing the medication was responsible for accuracy. Record review of the facility's Administering Medications policy dated December 2012 read in part, . Medications shall be administered in a safe and timely manner, and as prescribed .7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 4 of 9 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 05/09/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. Residents Affected - Many -The facility did not ensure plates in the kitchen were free of debris. These failures could place residents at risk of cross-contamination and foodborne illness. Findings include: Observation on 5/8/2024 at 11:43 AM revealed all foods were at an appropriate temperature. Two divided plates were observed under the steam table, on a shelf, with a small black substance on them, and one of the divided plates also had a metallic substance on it. The plates were on the top of two stacks of plates which were to be used for serving meals. Photographs were taken. Interview on 5/8/2024 at 11:53 PM with the DM, she said the black debris and metallic substance on two divided plates on the steam table was not appropriate. The DM said the staff should ensure cleanliness while working, and prior to serving any meals. The DM said the reason staff should ensure there was never any debris or other substances on a plate which would be used to serve residents was to avoid cross contamination or bacteria. The DM said the staff should check the plates or other dining items before placing any food on the plates. The DM said the plates were checked after being washed, and so she believed the black debris and metallic substance on the two divided plates came from either the steam table or when foil was taken off a dish coming out of the oven. The DM said the two divided plates were not acceptable for serving food to residents. The DM pulled two stacks of divided plates from the steam table area and took them to the dish washing area to be rewashed and sanitized after the black debris and metallic substance were identified during the survey process. Interview on 5/9/2024 at 11:03 AM with the Admin, he said he expected the kitchen to be cleaned at all times, and any spills or other messes to be cleaned immediately. The Admin said the substances on the two divided plates which were observed on 5/8/2024 during the survey should not have been on the steam table. The Admin said he expected that the plates should be cleaned prior to serving. The Admin said the dietary department was contracted, but the facility was moving to an in-house dietary department in the summer of 2024. The Admin said the staff do not go into the kitchen, but he did and he typically did not have any concerns with the sanitary conditions in the kitchen. Record review of the facility's Ware Washing policy dated 9/2017 revealed a policy statement which read All dishware, and utensils will be cleaned and sanitized after each use. Record review of the facility's Manual Ware Washing policy dated 9/2017 revealed a policy statement which read All cookware, dishware, and service ware that is not processed through the dish machine will be manually washed and sanitized. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 5 of 9 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 05/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 6 residents (Resident #18) reviewed for call lights. Residents Affected - Few -The facility failed to ensure Resident #18's call button by her bed was working. This failure could place residents at risk of injury, pain, and hospitalization. The findings include: Record review of Resident #18's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with an original admission date of 12/14/22. She had diagnoses of cerebral infarction due to occlusion/stenosis of left middle cerebral artery (stroke due to an artery in the brain being clogged), type 2 diabetes (body does not produce insulin or resists it), aphasia (trouble speaking), scabies (contagious, intensely itchy skin condition caused by a tiny, burrowing mite), vascular dementia (problems with reasoning, planning, judgment, memory caused by brain damage from impaired blood flow to brain), repeated falls, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and numbness after a stroke on the right side), and dysphagia (trouble swallowing). Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15, which indicated severely impaired cognition. She had impairment on one side of her upper and lower extremities and used a wheelchair. According to the MDS the resident was substantial/max assist with toileting hygiene, showers/baths, lower body dressing, and personal hygiene. She was always incontinent of bowel and bladder. The assessment revealed she had open lesions other than ulcers, rashes, or cuts, and was on isolation for active infectious disease. Record review of Resident #18's care plan dated 12/15/22, revealed a Focus: Resident is at risk for falls r/t impaired mobility (Initiated: 1/16/23, Revised: 1/18/23). Goal: Resident will be free of falls through the review date (Initiated: 1/16/23, Target: 6/27/24). Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Focus: Resident has rash (to the back) r/t Dx of scabies (contagious, intensely itchy skin condition caused by a tiny, burrowing mite), isolation in place (Initiated: 4/24/24, Revised: 4/24/24). Goal: Will have no s/sx of infection of the rash through the review date (Initiated: 4/24/24, Target: 6/27/24). Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Observe skin rashes for increased spread or signs of infection. Seek medical attention if skin becomes bloody or infected. Focus: The resident has an ADL self-care performance deficit r/t impaired mobility (Initiated: 12/29/22, Revised: 12/29/22). Goal: Resident will be cleaned, well-groomed, appropriately dressed and weight maintained through next review date (Initiated: 12/29/22, Target: 6/27/24). Interventions: Toilet Use: The resident requires extensive assist x 1 staff participation to use toilet. Bed Mobility: The resident requires extensive assist x 1 staff participation to reposition and turn in bed. Focus: Resident requires isolation due to contact isolation for scabies (contagious, intensely itchy skin condition caused by a tiny, burrowing mite) (Initiated: 4/24/24, Revised: 4/24/24). Goal: Resident will not have any psychosocial concerns and will no longer require isolation within the next 90 days (Initiated: 4/24/24, Target: 6/27/24). Interventions: Assure isolation is time limited. Follow facility isolation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 6 of 9 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 05/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Cypress Station 420 Lantern Bend Dr Houston, TX 77090 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 policy. Provide for in room visits and activities. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #18's Physician Orders revealed the following orders from MD A: Residents Affected - Few -Contact Isolation Precautions for Scabies (contagious, intensely itchy skin condition caused by a tiny, burrowing mite), every shift for 17 days. Ordered on 4/25/24 at 9:33am. In an Observation of Resident #18 on 5/7/24 at 6:54am, she had a contact isolation sign on her door. She was asleep in bed. Her call light was clipped to her bed and when the button was pushed the light on the wall did not come on and neither did the light outside the door. In an Observation and interview with Resident #18 on 5/8/24 at 9:10am, the call light was still not working. The resident was confused and not able to say how she reached staff if she needed help. Interview with CNA M on 5/8/24 at 9:15am, she said Resident #18 used her call button when she needed to reach staff. She was not aware the call light was not working and said she last checked on her after breakfast and she was fine at that time and did not need anything. The CNA said she checked on residents at least every 2hrs. She also said that leadership checked call bells every day. Interview with LVN L on 5/8/24 at 9:18am, she said Resident #18 calls staff with her call bell. LVN L did not know her call bell was not working. She said she gave her ice at about 7:45am and the resident was ok at that time. She said staff check the call bells daily when they go in at the beginning of the day. She said she was going to put in a request for maintenance to come fix it. LVN L said if the resident did not have a working call bell, lots of things could happen to the resident, including a fall. Interview with the DON on 5/8/24 at 10:50am, she said leadership checked call bells every morning during Angel Rounds. She said they did not check every room but would pick a few call bells randomly to try. She said no one had checked Resident #18's in the last few days. She said if the resident did not have a working call bell the resident could fall, but the resident was total care so she should be checked on at least every 2hrs. Record review of the facility's policy and procedure on Answering the Call Light (revised March 2012) read in part: The purpose of this procedure is to respond to the resident's requests and needs .Demonstrate the use of the call light. Ask the resident to return the demonstration so that you will be sure that the resident can operate the system .Be sure that the call light is plugged in at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Some residents may not be able to use their call light. Be sure you check these residents frequently. Report all defective call lights to the Nurse Supervisor promptly . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 7 of 9 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 05/09/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1 of 8 residents (Resident #12) reviewed for pests, in that: Residents Affected - Few -Resident #12 had one medium sized roach and approximately five small black ants crawling in bed with her. This failure could place residents at risk of residing in an environment with pests. Findings included: Record review of Resident #12's face sheet dated 5/9/24 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnosis included Alzheimer's disease, cognitive communication deficit, major depressive disorder, anxiety, psychotic disorder, and other reduced mobility. Record review of Resident #12's annual MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. She required assistance from staff for ADL care. Observation and Interview on 5/7/24 at 8:31 a.m. of Resident #12 revealed she was lying in bed. Resident #12 did not respond to this Surveyor's greeting. There was one roach crawling on the bed sheet near the head of the bed. This Surveyor left the room to alert staff. The Wound Care Nurse returned to the room with this Surveyor and observed approximately five small black ants crawling on the resident's bed sheet. The roach was no longer on the bed but was observed crawling down the call light toward the floor. The Wound Care Nurse stepped on the roach and said the bugs on the bed looked like ants. The Wound Care Nurse said she would notify a CNA to change the bedding and provide care for Resident #12. In an Observation and Interview on 5/7/24 at 8:40 a.m. of Resident #12 in bed revealed small black ants crawling on the sheet. CNA L said the bug looked like an ant and she would wash the resident's bottom to make sure she was clean. Interview on 5/7/24 at 1:11 p.m. the DON said Resident #12 may have had a night snack in her room. She said bugs should not be present in the room or the facility because it was unsanitary, and the resident could get bitten. She said staff conducted room rounds daily and as needed to ensure there were no pests or food crumbs. She said all staff were responsible to report if pests were seen. Interview on 5/7/24 at 1:27 p.m. the Administrator said the facility had a little problem with sugar ants and sometimes the residents left sweets out. He said there was no problem with roaches. He said pest control treated the facility monthly and in an emergency. He said the exterminator treated Resident #12's room (today) and said the bugs were sugar ants. He said it was important that the facility stayed free of pests because he did not want the resident to be bitten or susceptible to infection. He said staff were responsible for checking for pests and sweets that were left out. Record review of the facility's pest control invoice dated 5/7/24 revealed the facility received an emergency service to treat little black ants. Record review of the facility's Pest Control policy dated May 2008 read in part, Our facility shall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 8 of 9 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 05/09/2024 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 0925 Level of Harm - Minimal harm or potential for actual harm maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675986 If continuation sheet Page 9 of 9