Health inspection·November 6, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #76's blood sugar summary, documented by RN A, revealed her blood sugar was 168 mg/dL on 10/29/23 at 4:09 p.m. and 195 mg/dL on 10/29/23 at 7:09 p.m. In an interview on 10/31/23 at 10:35 a.m., Resident #76 said on Sunday night (10/29/23) a new nurse (RN A) on the 2 p.m. - 10 p.m. shift gave her short acting insulin. She said she crashed, had shakes, and was sweating. She said she pushed the call light and told CNA K that her sugar was dropping. She said CNA K left the room and told RN A. CNA K returned to the room and said the nurse did not say anything. Resident #76 asked CNA K to bring her 2 packs of sugar and cranberry juice. She said she drank the juice and sugar and felt better. She said later the 10 p.m. - 6 a.m. nurse, LVN B, checked her blood sugar and it was normal. She said RN A did not do anything and did not come down to see her. She said she had been diabetic for over 20 years and the short acting insulin caused her to crash quickly. In an interview on 11/2/23 at 11:43 a.m. Resident #76's MD said the facility did not report any hypoglycemic episodes to her regarding Resident #76. She said Resident #76 told her on Tuesday (10/31/23) that she took the short acting insulin, did not really eat, and had to drink juice. She said the resident could pass out if she did not receive juice or sugar. In an interview on 11/2/23 at 2:20 p.m., CNA K said around Monday (10/30/23) at approximately 8 p.m. Resident #76 told her that her blood sugar was dropping. She said Resident #76 was out breath, tired, slumped over, had slurred speech and was not like herself. She said she felt it was an immediate situation. CNA K said she left the room and told RN A and the nurse replied ok and did not do anything. CNA K said she went to the kitchen and got 2 cups of juice and 2 packs of sugar and took them to Resident #76. She said she told RN A that she was bringing the items down to Resident #76 and that she needed to go and check on her. She said RN A never checked the blood sugar before or after the incident. She said RN A was asleep and another nurse had to wake her up. CNA K said she brought the juices and sugar to Resident #76, and she drank one juice and the sugar and started to feel better. She said she reported the incident to the nurse on the next shift, LVN S. She said she also reported it to LVN E and the medication aide who worked 2-10 p.m. She said abuse and neglect should be reported to the nurse, DON, and to the Administrator. She said she did not report the incident to any other nurse because she was in panic mode and was not thinking. In a telephone interview on 11/2/23 at 3:28 p.m., LVN S said on Sunday (10/29/23) CNA K reported to her that an unknown resident's blood sugar was low, and that CNA K reported it to RN A but was unsure what the nurse (RN A) did or did not do. LVN S said she reported it to LVN B. In a telephone interview on 11/2/23 at 3:37 p.m., LVN B said when she arrived to work on Sunday night (10/29/23, 10 p.m. - 6 a.m. shift) LVN S told her to go check on Resident #76. She said she assessed Resident #76, and her blood sugar was 190 or 195. She said Resident #76 told her that her blood sugar dropped earlier, and the previous nurse did not check on her. LVN B said she gave the resident crackers and juice to have overnight. LVN B said RN A did not say anything about Resident #76's blood sugar during change of shift report. In a telephone interview on 11/2/23 at 3:41 p.m., RN A said she worked with Resident #76 on 10/29/23 and did not have any concerns with the resident during her shift. She said she gave Resident #76 insulin twice during her shift, one was long acting and the other was short acting. She said Resident #76 did not have any hypoglycemic episodes that she knew of. She said no aides reported anything to her regarding Resident #76. She said she was unaware if an aide gave juice or sugar to a resident and if so, the aides did not tell the nurse. She said Resident #76 would sometimes refuse her short (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 2 of 6 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 675991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Humble 19424 McKay Dr Humble, TX 77338 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 acting insulin because it would make her feel bad. She said she did not doze off at the nursing station. Level of Harm - Minimal harm or potential for actual harm In an interview on 11/2/23 at 5:16 p.m., the DON said she was just notified of the incident with Resident #76. She said CNA K did not report it to her at the time and did not tell anyone else. She said she expected the nurse to get up and go see about the resident because she could go into a coma. She said the nurse should have completed a hypoglycemic assessment and notified the MD. She said LVN E reported to her on Monday 10/30/23 that RN A dozed off at the nursing station. She said she provided a one-to-one in-service with her. Residents Affected - Few In an interview on 11/2/23 at 5:42 p.m., the Administrator said he just learned of the incident with Resident #76. He said CNA K did not report it to anyone. He said the facility started in-services staff on calling the DON or Administrator if the nurse does not react. He said RN A had been written up previously and was about to be termed due to previous concerns including lack of knowledge. In a telephone interview on 11/3/23 at 10:52 a.m., the NP said Resident #76's blood sugar ranged from 80-200. He said the resident would often refuse her insulin because she felt her blood sugar would drop. He said he had not seen or heard of a hypoglycemic episode with Resident #76. In an interview on 11/3/23 at 11:54 a.m., the Administrator said CNA K should have called the DON and reported the concern about Resident #76 to other nurses. He said she should not have waited to the end of the shift because it could lead to something serious. He said there was a gap when the facility was not responsive to Resident #76. In an telephone interview on 11/3/23 at 4:46 p.m., RN A said the facility fired her. Record review of RN A's 1 on 1 In-service Record dated 10/30/23 revealed the in-service topic: no sleeping while on clock. The nurse voiced understanding. The in-service was signed by the DON, RN A, and the Unit Manager. Record review of the facility's Insulin Administration policy dated April 2007 read in part, . Reporting: 2. Notify the physician if the resident has signs and symptoms of hypoglycemia that are not resolved by following the facility protocol for hypoglycemia management . Record review of the facility's Nursing Care of the Resident with Diabetes Mellitus policy dated April 2009 read in part, .3. Hypoglycemia (blood sugar below reference ranges). Signs and symptoms of hypoglycemia usually have a sudden onset and may include the following: a. weakness, dizziness, or faintness; b. restlessness and/or muscle twitching; e. excessive perspiration; . i. numbness of the tongue and lips/thick speech; j. stupor, unconsciousness and/or convulsions; and coma. If these, or other abnormal conditions exist, notify the physician (for hypoglycemia, follow steps in Management of Hypoglycemia below) . Management of Hypoglycemia . 3. For symptomatic (lethargic, drowsy) but responsive (conscious) residents with hypoglycemia (<70 mg/dl or less than the physician-ordered parameter): a 1. Immediately give the resident an oral form of rapidly absorbed glucose (4 oz juice or 5-6 ounces of soda); 2. Recheck blood glucose in 15 minutes; 3. Repeat juice if indicated, recheck blood glucose in 15 minutes. Record review of the facility's Change in a Resident's Condition policy dated April 2007 read in part, .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a. an accident or incident involving the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 3 of 6 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 675991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Humble 19424 McKay Dr Humble, TX 77338 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 observations, interviews, and record reviews the facility failed to maintain an effective pest control program so that it remains free of pests for 1 (Resident #53) of 24 residents and one area (The Conference Room) reviewed for pests. Residents Affected - Few -The facility failed to ensure the building was free of cockroaches and fruit flies. These failures could put residents at risk of, infection, allergies, skin irritation, unsanitary living conditions and decline in health and well-being. Findings include: Resident #53 Record review of Resident #53's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnosis included diabetes, paralysis to left side of body following a stroke, malnutrition, memory deficit, narrowing of the arteries, bipolar disorder (a mental disorder), dementia, delusional disorders, age related cognitive decline, elevated blood pressure and progressive lung disease. Record review of Resident #53's annual MDS dated [DATE] revealed a BIMS score of 11 out of 15 indicating moderate cognitive impairment. Section E revealed he had behaviors of rejecting care. Section G revealed he required extensive assistance with personal hygiene and supervision for eating and toilet use. Record review of Resident #53's undated care plan included: Focus - Resident #53 had ADL Self Care Performance Deficit r/t communication problems, inappropriate behavior, resistive behavior, dementia, incontinent episodes, unsteady gait, poor balance, and weakness. Goal - Will be cleaned, well-groomed, appropriately dressed through next review date. Interventions included - Eating: The resident requires supervision/set up help by staff participation to eat. During an observation and interview on 10/31/2023 at 3:20PM, Resident #53 room was at the end of 100 Hall. He was side lying in bed. There was a meal tray on the overbed table next to the bed. There were at least five large fruit flies on the uncovered bowl of sliced fruit. There were more fruit flies scattered on the empty dinner plate. Resident #53 did not say anything when he was told there were fruit flies. Resident #53 raised himself up and looked at the tray then lowered himself back on the bed. During an observation on 11/01/2023 at 12:30 PM, there was one live small cockroach found in the Conference Room on the carpeted floor. During an interview on 11/01/2023 at 2:00 PM, the DON stated the Maintenance Director was responsible to check for pests. The DON stated the facility has had cockroaches in the building and if problems persist with pests in a particular room, the resident would be removed and the whole room would be cleaned. The DON stated the meal trays from resident rooms are picked up by nursing staff once the residents have completed the meal. The DON stated some residents eat slowly and expected that when CNAs do their rounds, within an hour of finishing the meal they trays would be picked up. When asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 4 of 6 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 675991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Humble 19424 McKay Dr Humble, TX 77338 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 Residents Affected - Few about the fruit flies on Resident #53's tray the DON stated, she was not aware of it and the tray should have been picked up when he was done eating. During an interview on 11/03/2023 at 3:10 PM, the Maintenance Director stated pests have been an issue since he started working at the facility 2 years ago. He stated cockroaches have been in the building off and on and that it was a seasonal thing. He stated that pest control services come once a month or as needed and that it was important for infection control reasons. He stated that cockroaches were a nuisance and carry diseases. He stated for pests such as cockroaches and fruit flies, the pest control service technician would make recommendations such as: do not leave food out in the open and to keep food covered. During an interview on 11/05/2023 at 11:45 AM, LVN L stated she was in charge of 100 Hall. LVN L stated she would not wait for a CNA to clean up messes in resident rooms. She stated it was important to do so to keep bugs away and reduce germs when the resident eats in his room. She stated Resident #53 was very messy and so it was important to clean up as soon as possible. LVN L stated she did not know if Resident #53 had ever requested to leave a tray in the room. She stated she had not seen any bugs in his room and had not been in his room yet. When asked about the fruit flies that were found on Resident #53's tray, LVN L stated trays should be picked up after the resident was done with the meal. LVN L stated keeping food out of the room will keep bugs away as germs may get onto the food and the resident could get sick. LVN L said it would not be sanitary as the nursing staff deal with a lot of feces in resident rooms and bugs can get on to unclean surfaces then get onto food. LVN L stated keeping foods out of the rooms as much as possible to prevent the spread of germs and prevent illness. LVN L stated Resident #53 ate breakfast in the dining room and that she would make sure he eats lunch in the dining room as well. During a telephone interview on 11/06/2023 at 10:30 AM, the Administrator stated yes, the facility had cockroaches or other bugs in the building prior to the survey and at any time a report on pest sightings, the facility Maintenance Director will spray, or pest control services will come if there are multiple sightings. The Administrator stated that Resident #53's room was treated for fruit flies on Sunday 11/05/2023 and again during the morning of 11/06/2023. The Administrator stated Resident #53 likes to keep the window open from time to time and he said there was a screen on the window. The Administrator stated it was more of just an inconvenience, that no one wants to have fruit flies in the room. The Administrator stated the resident would be offered to move out of the room to perform a deep clean. He also stated that the facility would conduct a root cause analysis. The Administrator stated that the goal would be to manage the pests as best as possible. The Administrator stated that although it would not be possible to eliminate the pests, but it would be desirable. He said he was the person responsible to keep the building free of pests. The Administrator stated some residents like to keep food containers out and not every resident was going to be clean. He said his expectation from the staff would be to help keep the rooms clean by picking up the trays after the residents were done eating. Record review of the Pest Control Service Information dated 11/01/2023, re-service read in part: .Observed issue, one cockroach in 207 .Technician Comments .One nymph German cockroach was observed but nothing of major concern. room [ROOM NUMBER] next door was also inspected and treated out of precaution . Record review of the Pest Control Service Information dated 11/01/2023, monthly service, read in part: .Observed issues German cockroaches 115, 205, 208 .Site Recommendations .Conducive Conditions, limit or place food from nightstands in containers to limit .for pest .live activity was only found (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 5 of 6 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 675991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Humble 19424 McKay Dr Humble, TX 77338 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 in rooms 115, 205, 208 .kitchen also noted seeing gnats in the pantry . Level of Harm - Minimal harm or potential for actual harm Record review of the Pest Control Service Information dated 09/08/2023, monthly service read in part: .Technician Comments: .the main areas of concern were the far end of 300 hall and various areas of 100 and 400 halls. The kitchen had no noted issues since our previous visit, but I did notice some small flies .Active German cockroaches were seen in the Administration office . Residents Affected - Few Record review of the Pest Control Service Information dated 08/14/2023 for follow up visit read in part: .Technician Comments .room [ROOM NUMBER] .high volume of food debris around Bed A .room [ROOM NUMBER] .5 German Cockroaches were found .room [ROOM NUMBER] yielded nymph German cockroaches behind nightstand .302 .dead cockroach activity was found . Record review of the Pest Control Service Information dated 08/02/2023, monthly service read in part: .Technician Comments .Live German cockroaches observed in 305 and 304 .several German cockroach sightings were noticed in the actual hallway Record review of the facility policy and procedure for Pest Control, revised August 2008 read in part: Policy Statement - Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation - 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by pest control company. 3. Windows are screened at all times 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 6 of 6