Health inspection·October 15, 2024

F 0925 pressure ulcer of unspecified site, unstageable. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated she was cognitively intact. She required moderate assistance from staff for ADL care. Resident #2's active diagnoses included stroke, hypertension, and dementia. Residents Affected - Some Resident #3 Record review of Resident #3's face sheet dated 10/15/24 revealed an [AGE] year-old female who admitted on [DATE]. Her diagnoses included type 2 diabetes (high glucose), glaucoma (condition that damages the eye's optic nerve), morbid obesity, major depressive disorder, anxiety, and cognitive communication deficit. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 out of 15 which indicated she was cognitively intact. She required assistance from staff for ADL care. Resident #2's active diagnoses included she had medically complex conditions, hypertension, depression, and cognitive communication deficit. Observation and Interview on 10/15/2024 at 9:15 a.m. of Resident #1 revealed she was awake lying in bed. Resident #1 responded to this State Surveyor's greeting and said, I am tired. Resident #1 took a long sigh said she was tired from waking up throughout the night from swatting at and killing roaches that had been crawling in her bed. There was a roach crawling on the wall behind the resident's bed. There were two dead roaches that were flattened at her bedside. CNA A walked into Resident #1's room and killed the roach. CNA A left to notify the ADMIN. Resident #1 said she has had roaches in her bed and had to continuous swat them off her bed and they have crawled on her as well. She said she has told numerous staff every day. She said the facility said they had sprayed but she did not think it worked. In an interview on 10/15/2024 at 9:16 a.m. CNA A said she saw roaches in resident #1 and 2's room. She said she saw the roaches on Resident #1's bedside table and her bed. She said she documented the sightings in the pest control binder at the nurse's station. She said Resident #1 appeared tired when she rounded at the beginning of her shift (6:00 a.m.). She said the resident was at risk for skin irritation and fear of the roaches crawling on her. Observation and Interview on10/15/2024 at 9:22 a.m. of Resident #2 revealed she was sitting on the edge of her bed. She said she saw roaches in her room on the floor and her walls. Resident #2 had several roaches crawling on the floor and wall next to her bed. Resident #2's head was looking down and said she did not like the roaches in her room. She said it made her skin crawl. Observation and interview on 10/15/24 at 9:30 a.m. of Resident #3 revealed she was lying in bed. She said saw roaches crawl on her walls. She had a fly swatter and said she used it to kill roaches that crawled on her bed. She said the facility sprayed her room a few weeks ago but she said she still saw roaches. She said the pest control placed a roach motel in the room to catch the roaches. There was a green paper tube that was full of dead roaches. Interview on 10/15/2024 at 9:40 a.m. this State Surveyor notified the ADMIN about the roach activity observed. Interview on 10/15/24 at 1:42 p.m. with the ADMIS said she was assigned to Resident #2 for daily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 2 of 3 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 10/15/2024 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 Angel Rounds. She said angel rounds were performed daily to ask the residents if they had any concerns and check the room for any problems. She said she saw live and dead roaches in Resident #3's room last week. She said after she saw the roaches, she notified staff in the morning meetings. She said when she saw the live roaches, she did not bring it to Resident #3's attention and was not able to say how the resident reacted. Residents Affected - Some Interview on 10/15/24 at 1:50 p.m. with the Dir. of T&L said she had seen roaches in Resident #2's room from time to time. She said Resident #2 had complained about the roaches in her room and the Dir. of T&L said she advised staff in the morning meeting (consisted of department heads). She said she last saw roaches yesterday (10/14/24) but did not attend the morning meeting today because she had an appointment . In an interview on 10/15/24 at 1:57 p.m. the DON said she made daily rounds to identify any concerns in resident rooms. She said crumbs and food kept in the room by residents contributed to increased roach activity. She said pest control came monthly and when there were active sightings. She said the risk for residents was skin irritation. She said all staff were responsible for identifying pests in resident rooms. Interview on 10/15/24 at 2:12 p.m. the ADMIN said the facility staff performed ambassador rounds daily to identify resident concerns and/or room concerns. He said staff were instructed, if they saw any type of insect, to document it in the pest control binder. He said the facility had tried making sure open food was not in the rooms and deep cleaned the rooms when pests were found. He said the facility had monthly pest control and additional visits from pest control when activity was seen. He said roaches or any type of pest was not acceptable in resident rooms . Record review of facility pest control vendor service form dated 10/8/24 and 10/14/24 revealed the following: 10/8/24 - Reported Activity: Log book - German cockroaches in various rooms. Observed issues - German cockroach evidence. 10/14/24 - No facility log entries. Dead roaches found . Record review of the facility's Pest Control policy dated May 2001 (Revised May 2008) revealed the following read in part, Our facility shall 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 . Record review of the facility's pest control binder dated 9/9/24 - 10/15/24 revealed the facility had roach sightings in Resident #1's room on 10/15/24 and Resident #2's room on 9/30/24, 10/3/24, and 10/15/24. Pest control vendor has an entry that indicated the book was reviewed on 10/14/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675991 If continuation sheet Page 3 of 3