Health inspection·January 24, 2025

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 to remain free of pests and rodents for four of four residents and one of four halls. Residents Affected - Some The facility failed to ensure the building is free of cockroaches. This failure could place residents at risk of, infection, skin irritation, allergies, which could result in unsanitary living conditions and decline in health and well-being. Finding included: In an interview with Resident #37 on 01/23/2025 at 10:42am, Resident #37 stated the facility did have roaches and it's because a few residents eat in their rooms. Resident #37 stated there were times when they would try to stomp on the roaches with their shoe and would miss. When addressing the issue to the facility staff, Resident #37 was told it was a delusion of seeing the roaches, but an exterminator was brought in shortly after speaking with facility staff. The exterminator did place pellets along the side of the walls to kill any sighting of roaches. In an interview with Resident #21 on 01/24/2025 at 10:25am Resident #21 stated there was a concern with the roaches in the facility. Resident #21 also stated the last sighting of roaches was a couple of days ago in their room. Resident #21 also stated the roaches use to be worse, but things have gotten better over time. In an interview with MAINT on, 01/24/2025 at 9:08 am, MAINT stated the facility used an electronic request, which all staff members have access to log for seen pest, regardless of if they are alive or dead. There was also a logbook for any sightings of roaches that was reported by staff, which was checked daily, several times a day. The facility has had a roach issue within the last three months and used a pest control service. When there was a sighting of roaches in a specific hallway, the pest control company focused more on the hall that has the most sighting of roaches. The pest control does come out twice a month and is on call as needed. In an interview with CMA2 on 01/24/2025 at 10:34 am CMA2 said she had been at the facility for less than a month and normally worked a rotating shift CMA2 stated if a roach was in front of them, they would kill it, pick it, and contact maintenance or housekeeping to address the issues. In an observation on 1/24/25 at 11:25am, a small roach was seen in the conference room, crawling on the back of a chair by the Survey team. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675991 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 01/24/2025 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)