Health inspection·November 14, 2023

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility for approximately one month. She said she was working the 2 p.m. to 10 p.m. shift. She said her job responsibilities included checking and setting the O2 liters on the machines. She said Nurse B worked the morning shift and told her the Hospice Nurse changed Resident #2's O2 order today and increased it to 3L/minute. In an interview on 11/08/2023 at 3:40 p.m., Nurse B said she had been working at the facility for approximately 2 years and a few months. She said her job responsibilities included checking O2 settings and entering physician orders into the computer system. She said the Hospice Nurse came to the facility shortly after 12 p.m. today and assessed Resident #2. She said the Hospice Nurse changed Resident #2's O2 setting to 3L/minute. She said the hospice nurse gave a verbal order to increase Resident #2's O2 L/minute. In a telephone interview on 11/08/2023 at 4:13 p.m., the Hospice Nurse said she saw Resident #2 today between 1:00 p.m. and 1:30 p.m. She said she turned up the O2 liters on his machine to 3L/minute and reported it to LVN B. She said she told LVN B to report the change to Resident #2's doctor. Record review of the facility's Administering Medications policy, revised 12/2012, read in part .3. Medications must be administered in accordance with the orders, including any required time frame . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 2 of 4 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 11/14/2023 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 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 observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 (Resident #1) of 5 residents reviewed for resident call system. Residents Affected - Few -The facility failed to ensure Resident #1's call light was in working order. This failure could have placed residents at risk of not receiving assistance when needed. The findings included: Record review of Resident #1's admission Record, dated 11/14/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnoses included metabolic encephalopathy (a condition in which brain function is disturbed due to different diseases or toxins in the body), acute respiratory failure with hypoxia (condition where the lungs cannot provide enough oxygen to the blood), type 2 diabetes mellitus with hyperglycemia (high blood sugar), end stage renal disease (kidney failure), and acquired absence (loss or amputation) of right leg below knee Record review of Resident #1's quarterly MDS assessment, dated 10/17/2023, revealed a BIMS score of 11, indicating cognition was moderately impaired. Record review of Resident #1's care plan, undated, revealed she exhibited an ADL self-care performance deficit. Resident required as needed assistance with toileting, bathing, and eating. Further review revealed resident was a moderate risk for falls related to a balance problem. Interventions included encouraging resident to use call light for assistance as needed. Observation and interview on 11/14/2023 at 12:55 p.m., Resident #1 was in her room lying in bed. She said her call light sometimes worked, at other times did not work, and said it was a daily problem. The resident pushed her call light, and the light did not turn on. The resident pushed her call light again and the light did not turn on. Observation on 11/14/2023 at 1:53 p.m., Resident #1 pushed her call light, and it did not turn on. Observation on 11/14/2023 at 1:57 p.m., Nurse C pushed Resident #1's call light and the light turned on. She turned off the call light, pushed it again, and the light did not turn on. She said she did not know the call light was not working correctly and that the resident had not mentioned to her that the call light was not working properly. In an interview on 11/14/2023 at 2:05 p.m., the Maintenance Director said he had been working at the facility for approximately 2 years. He said his job responsibilities included checking and ensuring call lights worked. He said call lights were checked monthly. He said he was not aware Resident #1's call light was not working properly. He said staff never reported the issue to him verbally and/or submitted a work order. He said a non-working call light could pose a great risk to residents who require assistance with their care. He said he wanted all call lights to work at all times. Record review of the facility's Work Orders, Maintenance, revised 04/2010, read in part .1 .work (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 3 of 4 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 11/14/2023 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 0919 Level of Harm - Minimal harm or potential for actual harm orders must be filled out and forwarded to the Maintenance Director. 2. It shall be the responsibility of the department directors, charge nurse and/or certified staff to fill out and forward such work orders to the Maintenance Director through the TELS system. 3. Department managers, charge nurses, and certified staff have access to submit work orders . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 4 of 4