Health inspection·September 1, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Record review of CR #1's Quarterly MDS dated [DATE] revealed CR #1 had a BIMSs score of 3 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Residents Affected - Few Record review of Progress Note dated [DATE], written by LVN A revealed CR #1 fell at the facility at 2:00 p.m. on [DATE] and the x-ray was completed between 4:00p.m.-5:00p.m. On [DATE], his x-ray results came back at 9:55p.m. CR #1 was transported to the hospital on [DATE] at 1:13 PM. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 17:18 PM (5:18 PM) entered by LVN A, read in part, . CNA called the nurse from the nurse's station to activity room. Nurse arrived and saw resident lying on his left side on the floor. Resident complained of pain on the left leg when the nurse asked the resident. Assessment was done, no skin tear noted, no bruise noted, resident was able to move all his extremities, the CNA and the nurse assisted resident back to the wheelchair. CR #1 stated he was attempting to transfer himself without help from wheelchair to regular chair. Resident was assisted to bathroom after the fall without difficulty, no abnormality noted to both lower limbs or no sign and symptoms of pain noted. Tylenol prn 325mg 2 tablet was given as prescribed .NP gave orders for X-ray of left hip, femur ( thigh bone), knee ( joint flexes that is used to kneel), Tibia -fibula (two long bones in the lower leg), ulna radius (one of two bones that make up the forearm), shoulder, left forearm. DON notified; RP notified. Vitals blood Pressure 139/76, Respiration 18, Pulse 80, temperature.97.6, O2 sat 97% room. Neurological in place. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 22:00 PM (10:00 PM) entered by LVN B, read in part, . radiological labs received and seen at 2159 (9:59 PM). Examination: left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus ( upper arm bone) left elbow, left forearm. results received and reported to the oncoming nurse. NP notified of results. No NP's name and no impression from the left hip X-Ray noted. Record review of CR #1's comprehensive care plan dated [DATE] revealed that although high fall risk was care planned, all goals and interventions were either created or revised on [DATE] after several falls which occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The date initiated was on [DATE].CR #1 care plan was not revised until [DATE]. CR #1 passed away on [DATE]. Further review of CR #1's interventions revealed comprehensive care plan dated [DATE] had not been updated since [DATE] that he is a high risk for falls, related to balance problem, history of falls, unaware of safety needs, vision problem, as evidence by Fall Risk and assessment score 19. There were no fall risk interventions in place after his fall on [DATE]. Record review of CR #1's fall incident and accident report revealed on the following dates: [DATE]: Incident Location: CR #1's room: Resident slipped out of his wheelchair trying to get in the bathroom. [DATE]: Incident Location: CR #1's room: Resident lower himself to the floor from his wheelchair. He had a bowel movement and urinated on the floor. [DATE]: Incident Location: CR #1's room: Resident slipped to the floor while transferring to bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 2 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 without assistance. Level of Harm - Immediate jeopardy to resident health or safety [DATE]: Incident Location: CR #1's room: Resident ambulate without assistance. Residents Affected - Few Record review of CR #1's nurse's progress note documented by LVN A dated [DATE] at 11:00 AM written by revealed that a provider from private agency called for an update on the resident. Provider notified of radiological lab results and impression of the left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. [DATE]: Incident Location: Activity room on 300 hall: CR #1 found on the floor. Record review of CR #1's Progress Notes dated [DATE] at 13:05 PM (1:05 PM) entered by LVN A, indicated resident was picked by EMS via stretcher to be transferred to ER. Resident ate his lunch. Resident was calm and quiet. Paperwork was sent along with X-RAY results. RP and NP were notified of the transfer to ER. Interview with the DON on [DATE] at 11:14 AM, said CR#1 expired on [DATE], she said CR #1 fell on [DATE] in the activity room., it was not witnessed by another resident in the activity room because the activity assistant was busy transporting the resident to activity and there was nobody in the activity room. The DON said the facility was remodeling the dining area where they always have activities. She stated the resident was trying to transfer from the wheelchair to a chair when he fell, X-ray was done, and resident was sent to the hospital. The DON said the process of reporting X-ray report, was to call the on call doctor and notify. DON said the LVN B did not notify the on call NP of the impressions on the X-Ray and there were no new orders on [DATE]. Interview with Activity Director on [DATE] at 3:40 PM, she said she had been working in the facility for 5 years and they usually use the dining room for activities or activity room at end of 300 hall and always invite the residents for activity by assisting resident to activity room. Interview with the LVN A on [DATE] at 12:41 PM, LVN A said she was called to the activity room on 300 hall by a CNA, LVN A said she saw CR #1 lying on left side on the floor, CR #1 assessment was done. The DON, NP and RP was notified. This occurred at the change of shift at 2:00 PM, LVN A did not remember which CNA called her to CR #1's room. LVN A said while assessing CR #1 lying on his left side on the floor, CR #1 was saying ouch, ouch. She then assisted CR #1 to the wheelchair then transported him to his room. The NP gave her an order for an X-Ray at about 2:30 PM. LVN A said she was not around when the X-ray was done to CR #1. LVN A said an x-ray was ordered and it was done on 2p.m.-10 p.m. shift. LVN A said CR #1 was totally dependent on staff for transfer from wheelchair to bed and from bed to wheelchair and he was cognitively impaired. Interview with Activity Assistant B on [DATE] at 1:05 PM, he said he was transporting residents while CR #1 was in the activity room on 300 hall with other residents. He saw CR #1 on the floor. LVN A was already checking CR #1 and was taken to the room. Activity Assistant B confirmed that CR #1 was not able to ambulate, CR #1 was propelled by staff in the wheelchair. Interview on [DATE] at 10:30 AM, CNA A said she works 6:00 AM to 2:00 PM, she used to assist CR #1 with everything. She said she would transfer him to the wheelchair and bed, assist with incontinent care. She said his balance was unsteady. She said CR#1 was cognitively impaired and was not able to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 3 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 verbalize needs, CR#1 should not be left unattended. Level of Harm - Immediate jeopardy to resident health or safety Interview on [DATE] at 10:41 AM, with CNA B said she works 2:00 PM to 10:00 PM when came to work the [DATE] she was told CR #1 got up from the wheelchair and fell in the activity room. CNA B said she had been working at the facility for a year. She said there are two CNAs on each hall and CR#1 should not be left unattended. Residents Affected - Few Interview on [DATE] at 12:10 PM, the Administrator said he was told by LVN A that CR #1 had fallen in the activity room while Activity Assistant B was busy transporting residents for activities. The Administrator said CR #1 was left unattended with other residents. Administrator was responsible for abuse/neglect training. Interview with CR #1's NP on [DATE] at 4:00 PM, she said she was off duty from 6:00 PM on [DATE] and she saw CR #1's X-Ray faxed result on [DATE] at about 11:00 AM and that was why she called the facility to send him to the hospital. NP said she always see her residents daily in the facility and the licensed staff would call the on-call NP after hour (after 6:00 PM) to notify NP about the laboratory and X-ray reports. Interview on [DATE] at 2:12 PM, with LVN B he said he worked 2:00 PM to 10:00 PM for 3 months and he worked with CR #1. LVN B said he got the report on [DATE] from LVN A about CR #1's fall and the X-Ray technician came to the facility between 4:00PM and 5:00 PM and the result of the X-Ray came in at 9:55 PM. LVN B said he called NP agency on-call he was not sure the NP he spoke to and there was no new order. He read all examination to left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. LVN B said he did not read the impressions to the on-call person. LVN B was supposed to read ( Impression: Sub capital Left femoral neck fracture and Acute impacted sub capital left femoral neck fracture) Record review of CR#1's X-Ray exams result dated [DATE] revealed: Left hip 2 views: History: AP and cross table lateral do not manipulate. Findings: Right hip hemiarthroplasty ( partial hip replacement). An impacted sub capital left femoral neck fracture is noted. No other fracture or dislocation. IMPRESSION: Acute impacted sub capital left femoral neck fracture Record review of CR #1's Hospital interpretation & Diagnostics: Lab results interpretation Result: Recent Impressions: Cat Scan- CT Pelvis W/O Contrast [DATE] Impression: Sub capital Left femoral neck fracture CR #1 sustained a left sub-capital femoral neck fracture upon admission to the hospital, on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 4 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview with LVN A on [DATE] at 2:40 PM, LVN A said she worked 10:00 PM to 6:00 PM shift on [DATE] and LVN B told her about CR#1's X-Ray result and stated no order from the on-call NP. LVN A said she faxed X- Ray results to CR #1's regular NP at 11:00 PM on [DATE]. Interview on [DATE] at 12:01 PM, with MDS Coordinator A, said she had been the MDS nurse at the facility for 3 months and was behind was still learning/training with the cooperate nurses. She said she had been a nurse for just one year she is responsible for doing the MDS assessments, LTC's, annual and quarterly, newly admitted . She got her information from hospital records, therapist notes, CNA notes and wound care nurse notes. She said the nurses are responsible for acute care plans and care plan meetings. She said whatever triggers are from the MDS, they are added to the care plan. She said on [DATE], she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the DON are responsible for completing the fall risk assessments. Interview on [DATE] at 12:10 PM the Administrator said he was told LVN A hat CR #1 had fallen on [DATE], an X-ray was done and LVN B was not able to explain the impression on the X-ray result to the on call NP and this lead to a delay transferring CR #1 to the hospital. Interview on [DATE] at 3:52 PM, with RP, she said CR #1 had many falls, CR #1 did not fall in his room because he had camera in the room. RP said on [DATE] LVN A called her about CR #1 fall at 2:00 PM. On [DATE] the visiting NP found an X-Ray on [DATE] and called the RP and said that CR #1 was going to the hospital. she said CR #1 had declined after the surgical procedure done on [DATE] in the hospital NP said CR #1 had dementia Interview on [DATE] at 12:23p.m., with the ADON, she said the fall risk assessments are done on admission or when a resident has a fall and quarterly. ADON said does admission and quarterly assessments. She said if a resident falls, the nurses were supposed to assess the resident. She said if the resident can move, the nurse will put them back in the bed and notify the DON and their responsible party. She said the nurse will also take the resident's vitals. She said she knows a resident is a fall risk because they will have a yellow star at the foot of the bed. She said it will also be listed in the Kardex. She said the Kardex is in a binder on each station and in the PCC. She said when the nurse does an assessment for fall precautions, they determine what is care planned by meeting with the resident and the resident's family and they put the plans in place from there. She said if there is a fall at the facility, they take the post worksheets to the morning meetings. She said the DON puts the interventions in place with the nurse and address it with IDT team. ADON knew different form of abuse/neglect who to report it to including the state agency Interview on [DATE] at 2:01p.m., with LVN D said if a resident falls on her watch, she will call for assistance, complete a pain assessment, and if there is a head injury, she will have the resident sent out to the hospital. She said she will also notify the family, complete a progress not and a fall risk assessment. She said a fall risk assessment is completed when a resident is discharged or quarterly and if they have a fall. She said you will update the resident's care plan if they have a new fall or if the current plan isn't working. She said you know a resident is a fall risk because they will have a yellow star by the door and wheelchair. Interview on [DATE] at 6:00 PM, with the DON, said if a resident has a fall, she will assess them to make sure there are no injuries, call doctor and call the family. Residents will not be unattended while in activity. She said normally the nurse does the fall risk assessment, but lately she has been doing it. She said if there is a fall with a resident, she will review what happened, and will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 5 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 Level of Harm - Immediate jeopardy to resident health or safety conduct a morning meeting to see what needs should to be implemented for the care of the resident. She said the policy said, once there is a fall, they must do something about it which is to adjust the care plan and make an intervention. She did in-services on ANE. She said everyone on duty has been trained since they called the immediate jeopardy on the facility. She had She said the 2pm-10pm needs more training, but first shift and night shift has been trained. She said she had been coming in to work on different shifts to train each employee. Residents Affected - Few Interview on [DATE] at 6:30 PM, the DON said the resident was left unsupervised with the activity assistant. The activity assistant was transporting residents while CR #1 was alone in the activity room with other residents. She said CR #1 fell and they found him on the floor. She said he complained of pain to the left hip and an x-ray was ordered by the morning nurse (LVN A) and who also completed an assessment. She said that CR #1 was transported to the hospital and the family was notified. The DON said CR #1 was able to ambulate and able to make needs known and she in-services with LVN B on to document the name of the medical personal on and how to read X-ray results noting the impressions. In-services completed on [DATE]. Interview on [DATE] at 6:30 PM, the DON and the Administrator said the root cause was leaving CR #1 and other residents unattended and not calling the X-Ray in a timely. DON said she discussed the IDT fall in the morning meetings. Interview on [DATE] at 6:34 PM, the Administrator, said when a resident has a fall, the DON will call him, no matter the time. He said he will ask what happened and if the resident was able to explain what happened to them. He said he will have a stand-up meeting and standdown meeting. He said he will have a case management meeting, where the falls are discussed. He said the Quality Specialists have assignments and everyone has a sheet of the fall risk assessments. He said he does not participate in creating the care plans. He said he is a part of the huddle meetings and go over resident devices. Record review of facility policy Abuse, Neglect, Misappropriation of Property, date, on 10/2011 revealed: According to Nursing Home Reform Act of 1987, all residents in nursing homes are entitled to receive quality care and live in an environment that improves or maintains the quality of their physical and mental health. This entitlement includes freedom from neglect, abuse, and misappropriation of funds. Neglect and abuse are criminal acts whether they occur inside or outside a nursing home. Residents do not surrender their rights to protection from criminal acts when they enter a facility. This information sheet presents resident rights with regard to neglect and abuse, and steps to take if these rights are jeopardized. Neglect: Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional. For example, a caring aide who is poorly trained may not know how to provide proper care. Abuse: Abuse means causing intentional pain or harm. This includes physical, mental verbal, psychological, and sexual abuse, corporal punishment, unreasonable seclusion, and intimidation. Record Review of the facility's policy titled Fall and Post-Fall Management, undated, read in part, . Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for the resident as well as staff safety. Identify residents at risk for falls during ADL execution by resident individually or with staff assistance. Initiate preventative approaches. Provide appropriate strategies and interventions directed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 6 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 Level of Harm - Immediate jeopardy to resident health or safety to resident, environmental factors, and staff. Provide learning opportunities. Monitor and evaluate resident outcome . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:23 PM, due to the above failures. The Administrator, DON, Executive Director and Regional RN were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 5:23 PM. Residents Affected - Few The following Plan of Removal was submitted and accepted on [DATE] at 4:53 PM. Plan of Removal Park Manor Of Westchase [DATE] Submission #3 Immediate action: Other residents affected: a. CR #1 died on [DATE] b. On [DATE] an audit of Fall Risk Assessment was completed. Any resident who was identify as being at high risk for falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. Facilities Plan to Ensure Compliance: What corrective actions have been implemented for the identified residents? 1. The following action items were implemented immediately on [DATE]. a. CR #1 died on [DATE]. b. On [DATE] an audit of Fall Risk Assessments was completed. Any resident who was identified as being at high risk for falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 7 of 41 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 676059 B. Wing (X3) DATE SURVEY COMPLETED A. Building 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 2. Level of Harm - Immediate jeopardy to resident health or safety What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. Residents Affected - Few An in-service was initiated with licensed nurses on [DATE], by the Director of Nursing/designee, on implementing timely interventions post fall to include transfers to the hospital as indicated by the resident assessment. b. An in-service was initiated with licensed nurses on [DATE], by the DON/designee on immediately notifying the DON and/or Administrator of any falls with major injury such as a fracture. c. An in-service was initiated with licensed nurses on [DATE], by the DON/designee on neglect, to include falls with fractures. d. An in-service was initiated with licensed nurses on [DATE], by the DON/designee on reporting radiology results timely to the resident's nurse practitioner and/or physician when the results are received. The education included notifying the DON if the nurse practitioner and/or physician do not respond timely to the notifications. e. An in-service was initiated with direct care staff on [DATE], by the DON/designee on ensuring interventions are in place to prevent falls, including keeping a high-risk resident in an area that can be easily visualized by staff for safety when out of their room. f. An in-service was initiated with the Unit Managers, ADON, and MDS staff, by the DON on updating the care plan with new interventions timely after each fall. g. The Director of Nurses/designee will complete in-servicing on implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 8 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 h. Level of Harm - Immediate jeopardy to resident health or safety The DON/designee will in-service new hires during orientation on resident neglect, fall prevention and timely notification of radiology results to the physician and/or Nurse practitioner. i. Residents Affected - Few Educated/In-serviced nursing staff to notify the DON if X-Ray services do not respond in a timely manner Monitoring: The Administrator, DON, ADON and Rehab Director will conduct random weekly checks, on all shifts, on the high risk fall residents or any new admits implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. 3. How will the system be monitored to ensure compliance? a. The DON and Nurse Manger provided staff training and education on all high fall risk residents to assure assessments and care plans are updated. b. The DON and or Designee will review all radiology results to ensure they were communicated to the physician timely, and that interventions were implemented and added to the care plan to try to prevent falls. c. The DON and/or Nurse Managers will round on high fall risk residents daily to ensure safety measures are in place. Surveyor Monitored the plan of removal as follows: Observations were started on [DATE] and continued through [DATE]. Observation of Residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed bedrooms were free of clutter and adaptive devices were available for residents at risk for falls. Interviews were conducted on [DATE], [DATE], [DATE] with staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS Coordinator A, CNA A, CNA B, CNA C, LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, MA A, MA B, MA C,CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN H and LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 9 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few I. All staff interviewed verbalized adequate understanding of plan of remove training received including Abuse, Neglect and Expectation, Universal Fall Precautions policy/procedures, Kardex system, and Fall Prevention Procedures. Record review of the facility POR Binder revealed: Staff were in-serviced on [DATE], [DATE], regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls. Reporting, incidents, Kardex system and Fall Prevention Procedures. Reporting Radiology Results Timely. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights Record review of QAPI sign-in sheet revealed the facility held a QAPI on [DATE] to discuss and implement corrective action for CR#1's fall. Record review of the following Residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and CR #1) revealed Kardex Reports for residents at risk for falls had interventions in place to address falls. Record review of Kardex Binder revealed the facility had a binder at Nurse Station for halls #1, #2, #3 and #4 Record review of the following Residents (CR #1 #2, #3, #4, #5, #6, #7, #8, #9 #10 and #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed no care plans for residents at risk for falls. Record review of facility falls and fall risk, managing revised [DATE]: Policy Statement: Based on previous evaluations and current data, the staff will identify interviews related to the resident's specific risks and causes to try to minimize complications from falling. Policy interpretation and Implementation. Prioritizing Approaches to Managing Falls and Fall risk . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable. 6.In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 10 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention( e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exit that continue to present a risk for falling or injury due to falls. Record review of facility Safety and Supervision of Residents revised [DATE]: Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility -wide priorities. Policy Interpretation and Implementation . 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents 5. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify necessary. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 11 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0600 4. Level of Harm - Immediate jeopardy to resident health or safety Implementing interventions to reduce accident risks and hazards shall include the following: Residents Affected - Few Communicating specific interventions to all relevant staff, a. b. Assigning responsibility for carrying out interventions. c. Providing training as necessary. d. Ensuring that interventions are implemented e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed and d. Evaluating the effectiveness of new or revised interventions The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 2:45PM. The facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy, CR #1 sustained serious injury and passed due to the facili[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 12 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 20 residents CR #1(Closed Record) reviewed for abuse and neglect policies. Residents Affected - Few The facility failed to ensure CR #1 had adequate supervision to prevent an accident which resulted in a fall with major injury (left femur fracture) requiring surgery on [DATE]. The facility failed to read and notify the NP accurately of X-Ray results of CR #1's impression of left femur fracture resulting in delayed treatment. The facility failed to update CR #1's care plan and put interventions in place after continued falls, An Immediate Jeopardy (IJ) was identified on [DATE] at 5:23 PM. While the IJ was removed on [DATE] at 4:53 PM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy, CR #1 sustained serious injury and passed away due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of lack of communication with families and providing physicians following allegations of Abuse, Neglect, and Exploitation. Findings included: Record review of CR #1's face sheet revealed an [AGE] year-old male, date of admission was [DATE], readmission on [DATE], and died on [DATE]. CR #1's diagnoses included cerebrovascular disease ( a disease of the heart or blood vessels), contusion ( any collection of blood out a blood vessel) of eyeball and orbital tissues, unspecified eye, lack of coordination, muscle weakness (Generalized), cognitive communication deficit, dysphagia (difficulty swallowing ), oral phase, altered mental status, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities) unspecified severity, without behavioral disturbance, psychotic (when people lose some contact with reality) disturbance, mood disturbance and anxiety. Record review of CR #1's Quarterly MDS dated [DATE] revealed CR #1 had a BIMSs score of 3 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of Progress Notes documented by LVN A revealed CR #1 fell at the facility at 2:00p.m. on [DATE] and the x-ray was completed between 4:00p.m.-5:00p.m. [DATE], his x-ray results came back at 9:55p.m. CR #1 was transported to the hospital on [DATE] at 1:13 PM. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 5:18 PM entered by LVN A, read (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 13 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few in part, . CNA called the nurse from the nurse's station to activity room. Nurse arrived and saw resident lying on his left side on the floor. Resident complained of pain on the left leg when the nurse asked the resident. Assessment was done, no skin tear noted, no bruise noted, resident was able to move all his extremities, the CNA and the nurse assisted resident back to the wheelchair. CR #1 stated he was attempting to transfer himself without help from wheelchair to regular chair. Resident was assisted to bathroom after the fall without difficulty, no abnormality noted to both lower limbs or no sign and symptoms of pain noted. Tylenol prn 325mg 2 tablet was given as prescribed .NP gave orders for X-ray of left hip, femur, knee, Tibia-fibula, ( chin bone) ulna radius, shoulder, left forearm. DON notified; RP notified. Vitals blood Pressure 139/76, Respiration 18, Pulse 80, temperature.97.6, O2 sat 97% room.Neurological in place. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 22:00 PM entered by LVN B, read in part, . radiological labs received and seen at 2159. Examination: left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. results received and reported to the oncoming nurse. NP notified of results. No NP's name and no impression from the left hip X-Ray noted. Record review of CR #1's comprehensive care plan dated [DATE] revealed that although high fall risk was care planned, all goals and interventions were either created or revised on [DATE] which was well after several falls which occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The date initiated was on [DATE] and was revised on [DATE]. The resident passed away on [DATE]. Record review of CR #1's fall incident and accident report revealed on the following dates: [DATE]: Incident Location: CR #1's room: Resident slipped out of his wheelchair trying to get in the bathroom. [DATE]: Incident Location: CR #1's room: Resident lower himself to the floor from his wheelchair. He had a bowel movement and urinated on the floor. [DATE]: Incident Location: CR #1's room: Resident slipped to the floor while transferring to bed without assistance. [DATE]: Incident Location: CR #1's room: Resident ambulate without assistance. [DATE]: Incident Location: Activity room on 300 hall: CR #1 found on the floor. Further review of CR #1's interventions revealed comprehensive care plan have had not been updated since [DATE]. He is a high risk for falls, related to balance problem, history of falls, unaware of safety needs, vision problem, AEB Fall Risk and assessment score 19. There were no fall risk interventions in place after his fall on [DATE]. Record review of CR #1's of nurse's progress note documented by LVN B revealed that a provider from Health Agency called for an update on the resident. Provider notified of radiological lab results and impression of the left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. Record review of CR #1's Progress Notes dated [DATE] at 13:05 PM entered by LVN A revealed Resident was picked by EMS via stretcher to be transferred to ER. Resident ate his lunch. Resident was calm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 14 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 and quiet. Paperwork was sent along with X-RAY results. RP and NP were notified of the transfer to ER. Level of Harm - Immediate jeopardy to resident health or safety Interview with the DON (Director of Nurses) on [DATE] at 11:14 AM, she said resident CR#1 expired on [DATE]., sShe said the resident fell on [DATE] in the activity room, it was witnessed by another resident in the activity room because the activity assistant was busy transporting the resident to activity and there was nobody in the activity room. The DON said the facility was remodeling the dining area where they always have activity. Residents Affected - Few She stated that resident was trying to transfer from the wheelchair to a chair when he fell, X-ray was done, and resident was sent to the hospital. The DON said LVN B did not notify the on call NP of the impressions on the X-Ray and there werhoe no new orders on [DATE]. Interview with Activity Director on[DATE] at 3:40PM, she said she have been working in the facility for 5 years and they usually use dining room for activity or activity room at room at end of 300 hall always invite the residents for activity by assisting resident to activity room and not leaning resident not attended to. Interview with the LVN A on [DATE] at 12:41 PM, LVN A said she was called to the activity room on 300 hall by a C.NA. LVN A said she saw CR #1 lying on left side on the floor, CR #1 assessment was done. DON, NP and RP was notified. This occurred at the change of shift at 2:00 PM LVN A said while assessing CR #1 lying on left side on the floor, CR #1 was saying ouch, ouch. She then assisted CR #1 to the wheelchair then transported him to his room. NP gave her an ordered for X-Ray at about 2:30 PM. LVN A said she was not around when X-ray was done to CR #1. LVN A said an x-ray was ordered and it was done on 2p.m.-10p.m. shift. LVN A said CR #1 was totally dependent on staffs for transfer from wheelchair to bed and from bed to wheelchair, was cognitively. Interview with Activity Assistant B on [DATE] at 1:05 PM, he said was transporting residents while CR #1 was in the activity room on 300 halls with other residents. He said CR #1 fell found him on the floor and LVN A was already checking CR #1 and was taken to the room. Activity Assistant B confirmed that CR #1 was not able to ambulate, CR #1 was propelled by staff on the wheelchair. Interview on [DATE] at 10:30 AM with CNA A said she works 6:00 AM to 2:00 PM, she used to assist CR #1 with everything. She said she would transfer him to the wheelchair and bed, assist with incontinent care. She said his balance was unsteady. She said CR#1 was cognitively impaired was not able to verbalize needs. Interview on [DATE] at 10:41 AM, with CNA B said she works 2:00 PM to 10:00 PM when came to work on [DATE] she was told CR #1 got up from the wheelchair and fell in the activity room. C.NA B said she has been working at the facility for a year. She said there are two CNAs on each hall. Interview on [DATE] at 12:10 PM the Administrator said he was told by LVN A that CR #1 had fallen in the activity room while activity assistant B was busy transporting residents for activities. The Administrator said CR #1 was left unattended with other residents. He said CR #1. Interview with CR #1's NP on [DATE] at 4:00 PM, she said she was off duty from 6:00 PM on [DATE] and she saw CR #1's X-Ray faxed result on [DATE] at about 11:00AM and that was why she called the facility to send him to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 15 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on [DATE] at 2:12 PM with LVN B he said he worked 2:00PM to 10:00 PM for 3 months and he worked with CR #1. LVN B said he got the report from LVN A about CR #1 fall and X-Ray technician came to the facility between 4:00PM and 5:00 PM and the result of the X-Ray came in at 9:55 PM. LVN B said he called on team, he was not sure the NP he spoke with and there was no new order. He read all examination to left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. LVN B said he did not read the impressions to the on-call person and he knew different forms of abuse/neglect who to report it to, including the state. Record review of CR#1 X-Ray exams result dated [DATE] from the facility revealed: Left hip 2 views : History: AP and cross table lateral do not manipulate. Findings: Right hip hemiarthroplasty ( partial hip replacement) . An impacted sub capital left femoral neck fracture is noted. No other fracture or dislocation. IMPRESSION: Acute impacted sub capital left femoral neck fracture Record review of CR #1 Hospital interpretation & Diagnostics: Lab results interpretation Result: Recent Impressions: Cat Scan- CT Pelvis W/O Contrast [DATE] Impression: Sub capital Left femoral neck fracture CR #1 sustained a left sub-capital femoral neck fracture upon admission to the hospital, on [DATE]. Interview with the LVN A on [DATE] at 2:40 PM, LVN A said she worked the 10:00 PM to 6:00 PM shift on [DATE] and LVN B told her about CR#1's X-Ray result and stated no new order from the on-call NP. LVN A said she faxed the X- Ray result to CR #1's regular NP at 11:00 PM on [DATE] because she saw the impression of fracture on the X-ray . Interview on [DATE] at 12:01 PM with MDS Coordinator A, said she has been the MDS nurse at the facility for 3 months and was behind was still learning/training with the cooperate nurses. She said she has been a nurse for just one year she is responsible for doing the MDS assessments, LTC's, annual and quarterly, newly admitted . She got her information's from hospital records, therapist notes, C.NA notes and wound care nurse notes. She said the nurses are responsible for acute care plans and care plan meetings. She said whatever triggers are from the MDS, they are added to the care plan She said on [DATE], she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the DON are responsible for completing the fall risk assessments. Interview on [DATE] at 12:10 PM the Administrator said he was told by LVN A that CR #1 had fallen on [DATE], X-ray was done and LVN B was not able to explain the impression on X-ray result to on call NP and this lead to delay transferring CR #1 to the hospital. Administrator and DON were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 16 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 responsible for ANE and they do random rounds and talk to residents. Level of Harm - Immediate jeopardy to resident health or safety Interview on [DATE] at 3:52 PM, with RP, she said CR #1 had many falls, CR #1 did not fall in his room because he had camera in the room. RP said on [DATE] the nurse called her about CR #1 fall at 2:00 PM. On [DATE] the visiting NP found X-Ray on [DATE] and call RP that CR #1 was going to the hospital. RP said NP said the facility did not receive a death certificate for CR #1, she said CR #1 had declined after the surgical procedure. NP said CR #1 had diagnosis of dementia. Residents Affected - Few Interview on [DATE] at 12:23p.m., with the ADON, she said the fall risk assessments are done on admission or when a resident has a fall and quarterly. She said admission assessments that are done quarterly, is assigned to her. She said if a resident falls, she is supposed to assess the resident. She said if the resident can move, the nurse will put them back in the bed and notify the DON and their responsible party. She said the nurse will also take the resident's vitals. She said she knows a resident is a fall risk because they will have a yellow star at the foot of the bed. She said it will also be listed in the Kardex. She said the Kardex is in a binder on each station and in the PCC. She said when the nurse does an assessment for fall precautions, they determine what is care planned by meeting with the resident and the resident's family and they put the plans in place from there. She said if there is a fall at the facility, they take the post worksheets to the morning meetings. She said the DON puts the interventions in place with the nurse and address it with IDT team. Interview on [DATE] at 2:01p.m., with LVN D said if a resident falls on her watch, she will call for assistance, complete a pain assessment, and if there is a head injury, she will have the resident sent out to the hospital. She said she will also notify the family, complete a progress not and a fall risk assessment. She said a fall risk assessment is completed when a resident is discharged or quarterly and if they have a fall. She said you will update the resident's care plan if they have a new fall or if the current plan isn't working. She said you know a resident is a fall risk because they will have a yellow star by the door and wheelchair. Interview on [DATE] at 6:00 PM, with the DON, said if a resident has a fall, she will access them to make sure there are no injuries, call doctor and call the family. Residents will not be left unattended while in activity. She said normally the nurse does the fall risk assessment, but lately she has been doing it. She said if there is a fall with a resident, she will review what happen, and will conduct a morning meeting to see what needs should to be implemented for the care of the resident. She said the policy said, once there is a fall, they must do something about it which is to adjust the care plan and make an intervention. She said everyone on duty has been trained on falls, ANE since they called the immediate jeopardy on the facility. She said the 2pm-10pm needs more training, but first shift and night shift has been trained. She said she has been coming in to work on different shifts to train each employee. Interview on [DATE] at 6:30 PM with the DON said the resident was left unsupervised with the activity assistant. The activity assistant was transporting residents while CR #1 was alone in the activity room with other residents. She said the CR #1 fell and they found him on the floor. She said he complained of pain to the left hip and an x-ray was ordered by the morning nurse (LVN A) and completed an assessment. She said that CR #1 was transported to the hospital and the family was notified. DON said CR #1 was able to ambulate and able to make needs known and she in-services LVN B on to document the name of the medical personal on and how to read X-ray results noting the impressions Followed-up interview on [DATE] at 6:30 PM, the DON and the Administrator, said the root cause was leaving CR #1 and other residents unattended and not calling X-Ray in a timely. DON said she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 17 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 discussed the IDT fall in the morning meetings. Level of Harm - Immediate jeopardy to resident health or safety Interview on [DATE] at 6:34 PM, with the Administrator, said when a resident has a fall, the [NAME] DON will call him, no matter the time. He said he will ask what happened and if the resident was able to explain what happened to them. He said he will have a stand-up meeting and standdown meeting. He said he will have a case management meeting, where the falls are discussed. He said the Quality Specialists have assignments for any fall intervention and everyone has a sheet of the fall risk assessments. He said he does not participate in creating the care plans. He said he is a part of the huddle meetings and go over resident devices. Residents Affected - Few Record Review of the facility's policy titled Fall and Post-Fall Management, 10/2011, read in part, . Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for the resident as well as staff safety. Identify residents at risk for falls during ADL execution by resident individually or with staff assistance. Initiate preventative approaches. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff. Provide learning opportunities. Monitor and evaluate resident outcome . Record review of facility policy Abuse, Neglect, Misappropriation of Property, date, on 10/2011 revealed: According to Nursing Home Reform Act of 1987, all residents in nursing homes are entitled to receive quality care and live in an environment that improves or maintains the quality of their physical and mental health. This entitlement includes freedom from neglect, abuse, and misappropriation of funds. Neglect and abuse are criminal acts whether they occur inside or outside a nursing home. Residents do not surrender their rights to protection from criminal acts when they enter a facility. This information sheet presents resident rights with regard to neglect and abuse, and steps to take if these rights are jeopardized. Neglect: Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Neglect may or may not be intentional. For example a caring aide who is poorly trained may not know how to provide proper care. Abuse: Abuse means causing intentional pain or harm. This includes physical, mental verbal, psychological, and sexual abuse, corporal punishment, unreasonable seclusion and intimidation. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:23 PM, due to the above failures. The Administrator, DON, Executive Director and Regional RN were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 5:23 PM. The following Plan of Removal was submitted and accepted on [DATE] at 4:53 PM. Plan of Removal [DATE] Submission #3 Immediate action: Other residents affected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 18 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 a. Level of Harm - Immediate jeopardy to resident health or safety CR #1 died on [DATE] Residents Affected - Few On [DATE] an audit of Fall Risk Assessment was completed. Any resident who was identify as being at high risk for falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. b. Facilities Plan to Ensure Compliance: Resident with alleged deficient practice died on [DATE]. How were other residents at risk to be affected by this deficient practice identified? a. Nursing staff completed audit on all residents with high fall risk on [DATE]. All residents that have high fall risk were identified at risk to be affected by the alleged deficient practice, none found to be affected. Nursing staff audited the 72 hours Summary Report for all residents residing in the facility on [DATE] for any changes in condition, none identified. There were 19 total residents identified, no other residents were affected. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? a. An in-services was initiated by DON and/or designee on [DATE] with all staff on how to identifying residents who trigger for high fall risk and ensuring that safety measures are in place. b. An in -services was initiated on [DATE] by DON and/or designee with licensed nurses on reporting radiology results in a timely manner to the resident's nurse practitioner, and/or physician when results are received. Nursing staff must notify the DON if the nurse practitioner and/or physician do not respond in a timely manner. c. An in-service was initiated on [DATE] with licensed nurses that residents that triggered for high fall risk must have appropriate care plan interventions in place including placing residents who are at high-risk for falls in an area that can be easily visualized by staff for safety when out of room. Staff educated that the DON and/or administrator must be notified immediately of any falls with major injuries such as fracture. d. An in-service was initiated on [DATE] with ADON, and MOS staff by DON on updating care plans with new interventions timely after each fall including transfers to hospital as indicated by the resident assessment. e. Newly hired licensed nursing staff will be trained during the orientation process on reporting injuries related to falls and identifying residents who are at high risk for falls upon admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 19 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 f. Level of Harm - Immediate jeopardy to resident health or safety The Director of Nurses/designee will complete in-servicing on implementing timely interventions post fall, physician notification of radiology results, abuse/neglect and implementing timely fall interventions post fall and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. Residents Affected - Few Monitoring: The Administrator, DON, ADON and Rehab Director will conduct random weekly checks, on all shifts, on the high risk fall residents or any new admits implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. a. The DON and Nurse Manger provided staff training and education on all high fall risk residents to assure assessments and care plans are updated. b. The DON and or Designee will review all radiology results to ensure they were communicated to the physician timely, and that interventions were implemented and added to the care plan to try to prevent falls. c. The DON and/or Nurse Managers will round on high fall risk residents daily to ensure safety measures are in place. Surveyor Monitored the plan of removal as follows: Observations were started on [DATE] at different times, 8:30 AM, 9:30 AM, 11:00 AM, 2:30 PM, 3:30 PM, 4:30 PM, 5:50 PM, [DATE], 8:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM and continued through [DATE], 11:00 AM, 1:30 PM, 2:30 PM, 3:00 PM, 11:30 PM, 12:30 PM. Observation of Resident ((#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed bedrooms were free of clutter and adaptive devices were available for residents at risk for falls. Interviews were conducted on [DATE], [DATE], [DATE] with staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS Coordinator A, CNA A, CNA B, CNA C, LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, MA A, MA B, MA C,CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN H and LVN I. All staff interviewed verbalized adequate understanding of plan of remove training received including Universal Fall Precautions policy/procedures, ANE, Kardex system, and Fall Prevention Procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 20 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 Record review of the facility POR Binder revealed: Level of Harm - Immediate jeopardy to resident health or safety Staff were in-serviced on [DATE], [DATE], regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls. Reporting, incidents, Kardex system and Fall Prevention Procedures. Reporting Radiology Results Timely. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights. Residents Affected - Few Record review of QAPI sign-in sheet revealed the facility held a QAPI on [DATE] to discuss and implement corrective action for CR#1's fall. Record review of the following residents (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and CR #1) revealed Kardex Reports for residents at risk for falls had interventions in place to address falls. Record review of Kardex Binder revealed the facility had a binder at Nurse Station for halls #1, #2, #3 and #4 Record review of the following residents ( CR #1 #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed no care plans and intervention for residents at risk for falls in place to address falls. During an interview on [DATE] at 1:59p.m. with Regional RN said, she believes the facility currently has an IJ because of the resident's history of falls. She said the resident did not need a 1 on1 supervision, but because he had so many falls, it was a concern. She said when the residents are participating in activities, instead of staff taking residents back and forth, they should call for other staff members to come and get them. She said she wanted to make sure there is a system in place to move the residents back and forth to the activities area and that is a common area where other staff can see them. During an interview on [DATE] at 2:32p.m. the Administrator said, he believes the facility is currently has an IJ because there was a resident that fell and sustained a major injury. He said he has made sure that everybody understands how important it is to supervise residents. He said a big part of the morning meetings and meeting with quality assurance, is to make sure high-risk residents are always monitored. He said if there is a change in the environment, staff should know those changes and adapt to those changes. He said it is hard to do your job if you do not understand how to do certain things. He said he knows how staff is interacting with the residents by monitoring, walking around and observing what is happening on the floor and educating them with in-service trainings. During an interview on [DATE] at 1:33p.m. the ADON house said, she doesn't know why the facility has an IJ. She said she knew the incident that happened with the resident and that he had a fall. She said she was not working the day the resident had the fall. She said she could improve her work by being thorough with her documentation. She said all staff need to always monitor the residents at the facility. She said the fall risk residents she be around the nurse's station so that someone can keep a close eye on the residents. She said things would have gone differently if she was present at work during the incident with the resident. She said would have put interventions in place and care planned the falls based on how the falls happened. She said some of the trainings for staff are ongoing. She said she had a broad view on how to care for the residents. She said the purpose of having in-service training is so that staff understands how to take care of the residents. She said things change and staff must continue to receive training to adapt to those changes. She said she knows that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 21 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few staff can do their job because she follows ups with them every day and she have them to show her how to perform their job duties. During an interview on [DATE] at 1:42p.m. with RN she said the facility has an IJ because there was a resident with frequent falls, and they did not move to prevent him for falling and it resulted in his death. She said she learned that when they have a problem everyone has a problem. She said direct staff had a better idea for interventions that she does. She said she shared with the team that a resident had a fall. She said they went back and reviewed what was going on with the resident. She said for now on she is going to pay closer attention to the residents that are high risk for falls. She said the care plans will be closely directed to the resident. She said she will work closer with the activities director and document to show that the residents are being monitored. She said staff need to be educated and reeducated when things are ongoing regarding in-service. She said she would go back and ask questions to staff and have them to demonstrate on the computer what they are supposed to be doing to make sure they understand how to do their job properly. She said staff needs more training on how to create care plans. She said the care plans was not being done correctly since she has been at the facility. She said the care plans needs to be individualized. Record review of facility falls and fall risk, managing revised [DATE]: Policy Statement: Based on previous evaluations and current data, the staff will identify interviews related to the resident's specific risks and causes to try to minimize complications from falling. Policy interpretation and Implementation. Prioritizing Approaches to Managing Falls and Fall risk . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable. 6.In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 5. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 6. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention( e.g., dizziness or weakness) has resolved. 7. If the resident continues to fall, staff will re-evaluate the situation and whether it is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 22 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0607 Level of Harm - Immediate jeopardy to resident health or safety appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. 8. [TRUNCATED] Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 23 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure allegations of abuse and neglect are thoroughly investigated and report results of the investigation to the stage agency within 5 working days of the incident for 1 of 5 residents (Resident #19) reviewed for allegations of neglect as evidence by: The facility did not complete an investigation regarding Resident #19's complaint and report the findings to the agency within 5 working days. This failure could place residents at the facility in jeopardy of having their complaints and concerns reported and investigated for potential mental, physical, or emotional abuse. Findings included: Record review of Resident #19's face sheet revealed a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Her diagnosis was morbid obesity (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a (BMI) of 35 or higher and is experiencing obesity-related health conditions), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), gastro-esophageal reflux disease (occurs when stomach acid or bile flows into the pipe and irritates the lining), and dermatitis (inflammation of the skin). Record review of Resident #19's Comprehensive MDS assessment dated [DATE] revealed Resident #19 had a BIMs score of 11 indicating the resident was moderately cognitively impaired. The resident required extensive assistance with two persons physical assist with bed mobility. She required extensive assistance and one-person physical assistance for dressing, total dependence and one person's assistance for toilet use, supervision for eating, and extensive assistance and two persons assistance for transfer. She also requires extensive assistance and one-person assistance for personal hygiene. During observation and interview on 7/18/2023 at 10:48a.m., with Resident #19, revealed her lying in bed with a bed tray over her bed. She had an oxygen machine, and the machine was in use. She said she was once assigned to 100 hall and was moved to 400 hall because she had an incident with a CNA B. She said she requested for CNA B to be removed as her direct aid. She said when CNA B changed her adult brief, he would ask her to open her legs and would put his head between her legs and look at her private area. She said she found out after she made her complaint that CNA B could only work 100 hall because he had similar complaints. She said she liked her roommate on 100 hall and did not want to be moved. During an interview on 7/18/2023 at 3:03p.m. with the Administrator, he said he does not remember a complaint from Resident #19 being provided to him. He said CNA B has worked multiple hallways. He said he has given education and trainings. He said he does not remember Resident #19 complaining about staff doing something to her. He said CNA B would have given bedside manner training. He said he would have reported it if Resident #19 made allegations to him that something inappropriate happened. He said a grievance was not filed. In an interview on 09/01/23 at 2:43 PM ADON stated Resident #19 requested to be moved to another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 24 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hallway. The ADON could not recall the reason why. Resident #19 was on the 100 hallway and then she requested to be moved to the 400 hallway. In an interview on 09/01/23 at 2:56 PM the Social Worker stated she was informed that Resident #19 changed rooms a few months ago. The Social Worker was on leave the time of the move. Resident #19 was moved on 5/25/23 from 100 hall to 400 hall. The Social Worker was not a part of the discussions when Resident #19 changed rooms. Resident #19 is currently at the hospital. The Social Worker later heard that the Resident #19 was made uncomfortable by a staff member but could not provide any further details. During an interview on 9/1/2023 at 5:04p.m., with CNA B said it has been a long time since he worked with Resident #19. He said they moved her from 100 hall to the opposite hall. He said it has been less than a year since Resident made allegations against him. He said he has always worked 100 hall. He said when he came back to work after being off for two days, he was told that a female resident did not want a male aide to provide care for her. He said it was a general statement. He said nothing happened between him and Resident #19. He said he never worked with her alone. During an interview on 9/1/2023 at 3:21pm LVN D said she has been working at the facility since 2020. She said she has never heard of a male staff member being inappropriate with a female resident. She said Resident #19 came to her hall (400) and never complained about a male staff member. She said Resident #19 can communicate well. She said she makes sense and talks sensibly. She said if she found out something inappropriate was going on with a staff member and a resident, she would report it immediately to the Administrator, and the DON. During a follow-up telephone interview on 9/1/2023 at 3:47p.m., with the Administrator, said the allegations made by Resident #19 was not investigated because she never reported an allegation of abuse. He said he assigned a new aide to assist with Resident #19 since she did not like the care technique CNA B provided. He said Resident #19 only said that CNA B was too rough, and he thought she had a preference. He said Resident #19 requested to be move. He said he does not have issue with reporting abuse. He said there were no allegation of sexual assault, or any abuse. During a follow-up interview on 9/1/2023 at 5:26p.m. the Executive Director said the Administrator should have reported to the state when he was made aware of the allegations by the surveyor. He said it should have been documented as well. He will report the incident to the state agency. Record Review of the facility's policy titled Abuse Investigations, (revised 12/2009) read in part . All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required state or local laws, within (5) working days of the reported incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 25 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0610 Respond appropriately to all alleged violations. 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 allegations of abuse and neglect are thoroughly investigated and report results of the investigation to the stage agency within 5 working days of the incident for 1 of 5 residents (Resident #19) reviewed for allegations of neglect as evidence by: Residents Affected - Few The facility did not complete an investigation regarding Resident #19's complaint and report the findings to the agency within 5 working days. This failure could place residents at the facility in jeopardy of having their complaints and concerns reported and investigated for potential mental, physical, or emotional abuse. Findings included: Record review of Resident #19's face sheet revealed a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Her diagnosis was morbid obesity (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a (BMI) of 35 or higher and is experiencing obesity-related health conditions), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), gastro-esophageal reflux disease (occurs when stomach acid or bile flows into the pipe and irritates the lining), and dermatitis (inflammation of the skin). Record review of Resident #19's Comprehensive MDS assessment dated [DATE] revealed Resident #19 had a BIMs score of 11 indicating the resident was moderately cognitively impaired. The resident required extensive assistance with two persons physical assist with bed mobility. She required extensive assistance and one-person physical assistance for dressing, total dependence and one person's assistance for toilet use, supervision for eating, and extensive assistance and two persons assistance for transfer. She also requires extensive assistance and one-person assistance for personal hygiene. During observation and interview on 7/18/2023 at 10:48a.m., with Resident #19, revealed her lying in bed with a bed tray over her bed. She had an oxygen machine, and the machine was in use. She said she was once assigned to 100 hall and was moved to 400 hall because she had an incident with a CNA B. She said she requested for CNA B to be removed as her direct aide. She said when CNA B changed her adult brief, he would ask her to open her legs and would put his head between her legs and look at her private area. She said she found out after she made her complaint that CNA B could only work 100 hall because he had similar complaints. She said she liked her roommate on 100 hall and did not want to be moved. During an interview on 7/18/2023 at 3:03p.m. with the Administrator, he said he does not remember a complaint from Resident #19 being provided to him. He said CNA B has worked multiple hallways. He said he has given education and trainings. He said he does not remember Resident #19 complaining about staff doing something to her. He said CNA B would have given bedside manner training. He said he would have reported it if Resident #19 made allegations to him that something inappropriate happened. He said a grievance was not filed. In an interview on 09/01/23 at 2:43 PM ADON stated Resident #19 requested to be moved to another hallway. The ADON could not recall the reason why. Resident #19 was on the 100 hallway and then she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 26 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0610 requested to be moved to the 400 hallway. Level of Harm - Minimal harm or potential for actual harm In an interview on 09/01/23 at 2:56 PM the Social Worker stated she was informed that Resident #19 changed rooms a few months ago. The Social Worker was on leave the time of the move. Resident #19 was moved on 5/25/23 from 100 hall to 400 hall. The Social Worker was not a part of the discussions when Resident #19 changed rooms. Resident #19 is currently at the hospital. The Social Worker later heard that the Resident #19 was made uncomfortable by a staff member but could not provide any further details. Residents Affected - Few During an interview on 9/1/2023 at 5:04p.m., with CNA B said it has been a long time since he worked with Resident #19. He said they moved her from 100 hall to the opposite hall. He said it has been less than a year since Resident made allegations against him. He said he has always worked 100 hall. He said when he came back to work after being off for two days, he was told that a female resident did not want a male aide to provide care for her. He said it was a general statement. He said nothing happened between him and Resident #19. He said he never worked with her alone. He said she is overweight, and he needed someone to assist him with care. He said he has never trained anyone on how to take care of Resident #19. During an interview on 9/1/2023 at 3:21pm LVN D said she has been working at the facility since 2020. She said she has never heard of a male staff member being inappropriate with a female resident. She said Resident #19 came to her hall (400) and never complained about a male staff member. She said Resident #19 can communicate well. She said she makes sense and talks sensibly. She said if she found out something inappropriate was going on with a staff member and a resident, she would report it immediately to the Administrator, and the DON. During a follow-up telephone interview on 9/1/2023 at 3:47p.m., with the Administrator, said the allegations made by Resident #19 was not investigated because she never reported an allegation of abuse. He said he assigned a new aide to assist with Resident #19 since she did not like the care technique CNA B provided. He said Resident #19 only said that CNA B was too rough, and he thought she had a preference. He said Resident #19 requested to be moved. He said he does not have issue with reporting abuse. He said there were no allegation of sexual assault, or any abuse. During a follow-up interview on 9/1/2023 at 5:26p.m. the Executive Director said the Administrator should have started an investigation when he was made aware of the allegations by the surveyor and established if the alleged allegations happened. He said it should have been documented as well. Record Review of the facility's policy titled Abuse Investigations, (revised 12/2009) read in part . All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required state or local laws, within (5) working days of the reported incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 27 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise the comprehensive care plan for 1 of 5 residents (CR #1) reviewed for care plans in that: -- CR #1's care plan was not revised by staff after multiple falls and a fall with injury. Interventions in place were not current and updated on the plan of care. This failure affected 1 resident and placed an additional 20 residents with falls at risk of not having their individually assessed needs met to prevent further falls and to prevent resident injury, hospitalizations, and deaths. Findings include: Record review of CR #1's admission sheet revealed he was an [AGE] year-old male who was admitted to the facility on [DATE] and 7/09/2019 and re-admitted on [DATE]. His diagnoses included lack of coordination, muscle weakness, cognitive communication deficit, fall on same level (unspecified, subsequent encounter), displaced fracture of base neck of left femur (subsequent encounter for closed fracture with routine healing), chronic pain syndrome, anxiety disorder, cellulitis, and dysphagia. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed he had a BIMS score 03 indicating severely impaired. Record review of CR #1's Comprehensive Care Plan revealed that although his fall risk was care planned, all goals and interventions were either created or revised on 7/17/2023 which was well after several falls and occurred on 3/11/2022, 2/2/2023, 2/24/2023, 5/13/2023, 5/20/2023, 5/28/2023, and 7/6/2023. The date initiated was on 10/12/2021 and was revised on 7/17/2023. Record review of CR #1's Comprehensive Care Plan revealed that he is a high risk for falls, r/t balance problem, HX of falls, unaware of safety needs, vision problem, AEB Fall Risk and assessment score 19 meaning high risk. There were no fall risk interventions in place after his fall on 7/5/2023. The interventions have not been updated since 8/30/2020. During an interview on 07/20/2023 at 10:57a.m., with the [NAME] Nurse, said she was the person responsible for writing the care plans. She said at the time of the incident, was no longer employed at the facility. She said the facility had a new MDS nurse they had recently assigned, and the care plans would be checked every morning and the nurses were supposed to send out care plan letters and the care plans were reviewed by the Interdisciplinary Team. During an interview on 7/21/2023 at 12:01 PM with MDS Coordinator A, said she has been the MDS nurse at the facility for 3 months and was behind on the comprehensive care plans and was still learning/training with the cooperate nurses. She said she has been a nurse for just one year. She said she was responsible for doing the MDS assessments, LTC's, annual and quarterly, and newly admitted residents. She said she received her information from the hospital records, therapist notes, CNA notes and wound care nurse notes. She said the nurses are responsible for acute care plans and care plan meetings. She said the triggers are from the MDS, and they are added to the care plan. She said on the MDS assessment if it said limited assistance for toilet use, it means that resident needs assistance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 28 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to go to the bathroom. She said extensive assistance means he needs someone to help him all the time. She said she knows that CR #1 used his wheelchair, and he would say different words or wrote them down. She said he could not articulate his words. She said limited toilet use means moderate assist which means someone might need to watch him but not assist or they can help clean him. She said it was a difference when it comes to extensive assistance and limited assistance. She said if there was a care plan that says limited assistance and a MDS that says extensive assistance in a certain care area, it is a problem because it can affect the proper guidance or care that is needed for the resident. She said she cannot answer why the MDS assessment did not match the care plan. She said CR #1 was able to move around, and he was able to go leave his bed and go to the bathroom. She said when she did the MDS assessment for CR #1, he seemed to need extensive assistance. She said on 7/21/2023, she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the DON are responsible for completing the fall risk assessments. During an interview on 7/23/2023 at 1:42p.m. with DON, she said the facility has an IJ because there was a resident with frequent falls, and they did not move to prevent him for falling and it resulted in his death. She said she learned that when they have a problem everyone has a problem. She said direct staff had a better idea for interventions that she does. She said she shared with the team that a resident had a fall. She said they went back and reviewed what was going on with the resident. She said for now on she is going to pay closer attention to the residents that are high risk for falls. She said the care plans will be closely directed to the resident. She said she will work closer with the activities director and document to show that the residents are being monitored. She said staff need to be educated and reeducated when things are ongoing regarding in-service. She said she would go back and ask questions to staff and have them to demonstrate on the computer what they are supposed to be doing to make sure they understand how to do their job properly. She said staff needs more training on how to create care plans. She said the care plans was not being done correctly since she has been at the facility. She said the care plans needs to be individualized. Record Review of the facility's policy requested on 7/22/2023 was not provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 29 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 20 residents (CR #1 (Closed Record)) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure CR #1 had adequate supervision to prevent an accident on [DATE] which resulted in a fall with major injury (left sub-capital femoral neck fracture that resulted to him having surgery) on [DATE]. CR #1 declined and passed away on [DATE] after being released back to the facility from the hospital. The Facility failed to implement interventions after each incident of fall for CR #1 on, [DATE], [DATE] and [DATE], An Immediate Jeopardy (IJ) was identified on [DATE] at 5:23 PM. While the IJ was removed on [DATE] at 4:53 PM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy, CR #1 sustained servious injury and passed away due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents who require assistance with ADLs and place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings included: Record review of CR #1 of face sheet revealed [AGE] year-old male, date of admission was [DATE] readmission on [DATE] died on [DATE] diagnosis included cerebrovascular disease ( a disease of the heart or blood vessels), contusion ( any collection of blood out a blood vessel) of eyeball and orbital tissues, unspecified eye, lack of coordination, muscle weakness ( Generalized), cognitive communication deficit, dysphagia( difficulty swallowing ), oral phase, altered mental status, dementia ( the loss of cognitive functioning, thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities) unspecified severity, without behavioral disturbance, psychotic ( when people lose some contact with reality) disturbance, mood disturbance and anxiety. Record review of CR #1's Quarterly MDS dated [DATE] revealed CR #1 had a BIMSs score of 3 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #1's Comprehensive Care Plan revealed that although his fall risk was care planned, all goals and interventions were either created or revised on [DATE] which was well after several falls and occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The date initiated was on [DATE] and was revised on [DATE]. The resident passed away on [DATE]. Record review of CR #1's Comprehensive Care Plan revealed that he is a high risk for falls, related (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 30 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to balance problem, history falls, unaware of safety needs, vision problem, AEB Fall Risk and assessment score 19 meaning high risk. There were no fall risk interventions in place after his fall on [DATE]. The interventions have not been updated since [DATE]. Record review of CR #1's fall incident and accident report revealed on the following dates: [DATE]: Incident Location: CR #1's room: Resident slipped out of his wheelchair trying to get in the bathroom. [DATE]: Incident Location: CR #1's room: Resident lower himself to the floor from his wheelchair. He had a bowel movement and urinated on the floor. [DATE]: Incident Location: CR #1's room: Resident slipped to the floor while transferring to bed without assistance. [DATE]: Incident Location: CR #1's room: Resident ambulate without assistance. [DATE]: Incident Location: Activity room on 300 hall: CR #1 found on the floor. Record review of CR #1's care plan conference summary dated [DATE] addressed recent combative behavior towards other resident, falls related to cognitive decline. Recommendation for memory care unit due to recent behaviors and room safety. There were no outcome of the conference. The conference consists of the facility Administrator, DON, SW, ADON and RP, Ombudsman very via telephone. Record review of Progress Notes documented by LVN A revealed CR #1 fell at the facility at 2:00p.m. on [DATE] and the x-ray was completed between 4:00p.m.-5:00p.m. On [DATE], his x-ray results came back at 9:55p.m. CR #1 was transported to the hospital on [DATE] at 1:13 PM. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 5:18 PM entered by LVN A, read in part, . CNA called the nurse from the nurse's station to activity room. Nurse arrived and saw resident lying on his left side on the floor. Resident complained of pain on the left leg when the nurse asked the resident. Assessment was done, no skin tear noted, no bruise noted, resident was able to move all his extremities, the CNA and the nurse assisted resident back to the wheelchair. CR #1 stated he was attempting to transfer himself without help from wheelchair to regular chair. Resident was assisted to bathroom after the fall without difficulty, no abnormality noted to both lower limbs or no sign and symptoms of pain noted. Tylenol prn 325mg 2 tablet was given as prescribed .NP gave orders for X-ray of left hip, femur, knee, Tibia-fibula, ulna radius, shoulder, left forearm. DON notified; RP notified. Vitals blood Pressure 139/76, Respiration 18, Pulse 80, temperature.97.6, O2 sat 97%room. Neurological in place. Record review of CR #1's Progress Notes dated [DATE] (Late entry) at 10:00 PM entered by LVN B, read in part, . radiological labs received and seen at 9:59 PM. Examination: left hip, left femur, left knee, left tibia/fibula (shin), left shoulder, left humerus, left elbow, left forearm. results received and reported to the oncoming nurse. NP notified of results. No NP's name and no impression from the left hip X-Ray noted. There was no new order. Record review of CR #1's of nurse's progress note documented by LVN B revealed that a provider from Health Agency called for an update on the resident's X-ray. Provider notified of radiological lab results and impression of the left hip, left femur, left knee, left tibia/fibula, left shoulder, left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 31 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 humerus, left elbow, left forearm. Level of Harm - Immediate jeopardy to resident health or safety Record review of CR #1's Progress Notes dated [DATE] at 13:05 PM entered by LVN A read, Resident was picked by EMS via stretcher to be transferred to ER. Resident ate his lunch. Resident was calm and quiet. Paperwork was sent along with X-RAY results. RP and NP were notified of the transfer to ER. Residents Affected - Few Record review on [DATE] of CR #1's neurological assessment checks dated [DATE] revealed it was done by LVNA at 1:59 PM. Interview with the DON (Director of Nurses) on [DATE] at 11:14 AM, said resident CR#1 expired on [DATE]. sShe said the resident fell on [DATE] in the activity room, it was witnessed by another resident in the activity room because the activity assistant was busy transporting residents and there was nobody in the activity room. The DON said the facility was remodeling the dining area where they always have activities. She stated that CR#1 was trying to transfer from the wheelchair to a chair when he fell, an X-ray was done, and the resident was sent to the hospital. The DON said LVN B did not notify the on call NP of the impressions on the X-Ray and there were no new orders on [DATE]. Interview with the Activity Director on [DATE] at 3:40PM, she said she had been working in the facility for 5 years and they usually use the dining room for activity or activity room at end of 300 hall. Activities always invite the residents for activity by assisting residents to the activity room and residents should not be left unattended. Interview with the LVN A on [DATE] at 12:41 PM, LVN A said she was called to the activity room on 300 hall by a CAN CNA (Unknown). LVN A said she saw CR #1 lying on left side on the floor, an assessment was completed for CR #1. The DON, NP and RP were notified. This incident occurred during change at 2:00 PM. LVN A said while assessing CR #1 he was lying on his left side on the floor. CR #1 was saying ouch, ouch. She then assisted CR #1 to the wheelchair then transport him to his room. The NP gave her an ordered for X-Ray at about 2:30 PM. LVN A said she was not around when X-ray was completed. LVN A said an x-ray was ordered and it was done on the 2p.m.-10p.m. shift. LVN A said CR #1 was totally dependent on staffs for transfer from wheelchair to bed and from bed to wheelchair and monitored closely by keeping high risk for fall LVN A did SBAR assessment and documented in the progress note on [DATE]. Interview with Activity Assistant B on [DATE] at 1:05 PM, he said he was transporting residents while CR #1 was in the activity room on the 300 halls with other residents. He said CR #1 fell and they found him on the floor. LVN A was already checking CR #1 and took him to the room. Activity Assistant B confirmed that CR #1 was not able to ambulate, CR #1 was propelled by staff in the wheelchair. Activity Assistant B said he was not sure how long CR #1 was on the floor, he said probably was left unsupervised for about 10 to 20 minutes, he was transporting other residents for activity. Interview on [DATE] at 10:30 AM with CNA A said she worked 6:00 AM to 2:00 PM, she used to assist CR #1 with everything. She said she would transfer him to the wheelchair and bed, assist with incontinent care. She said his balance was unsteady. She said CR#1 was cognitively impaired and was not able to verbalize needs. Interview on [DATE] at 10:41 AM, with CNA B said she works the 2:00 PM to 10:00 PM shift. When she came to work the next morning, she was told CR #1 got up from the wheelchair and fell in the activity room. CNA B said she had been working at the facility for a year. She said there are two CNAs on each hall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 32 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on [DATE] at 12:10 PM the Administrator said he was told by staff that CR #1 had fallen in the activity room while Activity Assistant B was busy transporting residents for activities. The Administrator said CR #1 was left unattended with other residents. He said CR #1 had history of falls. Interview with CR #1's NP on [DATE] at 4:00 PM, she said she was off duty on [DATE] at 6:00 PM and she saw CR #1's faxed X-Ray result on [DATE] at about 11:00AM and that was why she called the facility to send him to the hospital. NP said on call person should have sent CR #1 out to the hospital. Interview on [DATE] at 2:12 PM with LVN B he said he worked 2:00 PM to 10:00 PM for 3 months and he worked with CR #1. LVN B said he got the report from LVN A about CR #1 ' s fall and the X-Ray technician came to the facility between 4:00PM and 5:00 PM and the result of the X-Ray came in at 9:55 PM. LVN B said he called the on call NP team at 9:55 PM, he spoke to a NP, but he was not sure which NP he spoke with and there were no new orders. He read all examination to left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. LVN B said he did not read the x-ray impressions to the on-call person. Interview with the DON (Director of Nurses) on [DATE] at 11:14 AM, she said LVN B did not notify on call NP of the impressions on the X-Ray and there were no new orders on [DATE] from the on call NP. DON said LVN B was a new nurse and she had a 1 on 1 in-service with LVN B. Record review of CR#1 X-Ray exams result dated [DATE] from the facility revealed: Left hip 2 views: History: AP and cross table lateral do not manipulate. Findings: Right hip hemiarthroplasty ( partial hip replacement). An impacted sub capital left femoral neck fracture is noted. No other fracture or dislocation. IMPRESSION: Acute impacted sub capital left femoral neck fracture Record review of CR #1 Hospital interpretation & Diagnostics: Lab results interpretation Result: Recent Impressions: Cat Scan- CT Pelvis W/O Contrast [DATE] Impression: Sub capital Left femoral neck fracture CR #1 sustained a left sub-capital femoral neck fracture upon admission to the hospital, on [DATE]. Interview with the LVN A on [DATE] at 2:40 PM, LVN A said she worked the 10:00 PM to 6:00 PM shift on [DATE] and LVN B told her about CR#1's X-Ray result and stated no order was given from the on-call NP. LVN A said she faxed X- Ray result to CR #1's regular NP at 11:00 PM on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 33 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on [DATE] at 12:01 PM with MDS Coordinator A, said she has been the MDS nurse at the facility for 3 months and was still learning/training with the cooperate nurses. She said she had been a nurse for just one year and she is responsible for doing the MDS assessments, LTC's, annually, quarterly, and the newly admitted . She got her information from the hospital records, therapist notes, CNA notes and wound care nurse notes. She said the nurses are responsible for acute care plans and care plan meetings. She said whatever triggers are from the MDS, they are added to the care plan. She said on [DATE], she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the DON are responsible for completing the fall risk assessments. Interview on [DATE] at 12:10 PM the Administrator said he was told by staff that CR #1 had fallen on [DATE], an X-ray was done and LVN B was not able to explain the impression on the X-ray result to the on call NP and this lead to delay in transferring CR #1 to the hospital. Interview on [DATE] at 3:52 PM, with RP, she said CR #1 had many falls, CR #1 did not fall in his room because he had camera in the room. RP said on [DATE] the nurse called her about CR #1 fall at 2:00 PM. On [DATE] the visiting NP found X-Ray on [DATE] and call RP that CR #1 was going to the hospital. RP said NP said the facility did not receive a death certificate for CR #1, she said CR #1 had declined after the surgical procedure. NP said CR #1 had dementia. Interview on [DATE] at 12:23p.m., with the ADON, she said the fall risk assessments are completed upon admission, quarterly or when a resident had a fall. She said admission and quarterly assessment were assigned to her for review. She said if a resident falls, she was supposed to assess the resident. She said if the resident can move, the nurse would put them back in the bed and notify the DON and their responsible party. She said the nurse will also take the resident's vitals. She said she knows a resident is a fall risk because they will have a yellow star at the foot of the bed. She said it will also be listed in the Kardex. She said the Kardex is in a binder on each station and in the PCC. She said when the nurse does an assessment for fall precautions, they determine what is care planned by meeting with the resident and the resident's family and they put the plans in place from there. She said if there is a fall at the facility, they take the post worksheets to the morning meetings. She said the DON puts the interventions in place with the nurse and address it with IDT team. Interview on [DATE] at 2:01p.m., with LVN D said if a resident falls on her watch, she will call for assistance, complete a pain assessment, and if there is a head injury, she will have the resident sent out to the hospital. She said she will also notify the family, complete a progress note and a fall risk assessment. She said a fall risk assessment is completed when a resident is discharged or quarterly and if they have a fall. She said you will update the resident's care plan if they have a new fall or if the current plan isn't working. She said you know a resident is a fall risk because they will have a yellow star by the door and wheelchair. Interview on [DATE] at 6:00 PM, with the DON, said if a resident has a fall, she will assess them to make sure there are no injuries, call the doctor, and call the family. Residents should not be left unattended while in activities. She said normally the nurse does the fall risk assessment, but lately she has been doing it. She said if there is a fall with a resident, she will review what happen, and will conduct a morning meeting to see what needs should to be implemented for the care of the resident. She said the policy said, once there is a fall, they must do something about it which is to adjust the care plan and implement interventions. She said everyone on duty has been trained since they called the immediate jeopardy on the facility. She said the 2pm-10pm needs more training, but first shift and night shift has been trained. She said she has been coming in to work on different (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 34 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 shifts to train each employee. Level of Harm - Immediate jeopardy to resident health or safety Interview on [DATE] at 6:30 PM with the DON said the resident was left unsupervised with the activity assistant. The activity assistant was transporting residents while CR #1 was alone in the activity room with other residents. She said the CR #1 fell and they found him on the floor. She said he complained of pain to the left hip and an x-ray was ordered by the morning nurse (LVN A) and who completed an assessment. She said that CR #1 was transported to the hospital and the family was notified. The DON said CR #1 was able to ambulate and able to make needs known and she in-services with LVN B on documenting the name of the medical personnel and on how to read X-ray results noting the impressions. Residents Affected - Few Followed-up interview on [DATE] at 6:30 PM, with the DON and the Administrator, said the root cause was leaving CR #1 and other residents unattended and not calling x-ray results timely into the physician. She said she discussed the IDT fall in the morning meetings. Interview on [DATE] at 6:34 PM, with the Administrator, said when a resident has a fall, the DON will notify him, no matter the time. He said he will ask what happened and if the resident was able to explain what happened to them. He said he will have a stand-up meeting and stand-down meeting. He said he will have a case management meeting, where the falls are discussed. He said the Quality Specialists have assignments and everyone has a sheet of the fall risk/intervention assessments. He said he does not participate in creating the care plans. He said he is a part of the huddle meetings and goes over resident devices. Record Review of the facility's policy titled Fall and Post-Fall Management, undated, read in part, . Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for the resident as well as staff safety. Identify residents at risk for falls during ADL execution by resident individually or with staff assistance. Initiate preventative approaches. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff. Provide learning opportunities. Monitor and evaluate resident outcome . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:23 PM. The Administrator, DON, Executive Director and Regional RN were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 5:23 PM. The following Plan of Removal was submitted and accepted on [DATE] at 4:53 PM. Plan of Removal [DATE] Submission #3 Immediate action: Other residents affected: CR #1 died on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 35 of 41 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 676059 B. Wing (X3) DATE SURVEY COMPLETED A. Building 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] an audit of Fall Risk Assessment was completed. Any resident who was identify as being at high risk for falls was falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. Facilities Plan to Ensure Compliance: What does the facility need to change immediately to keep residents safe and ensure it does not happen again? What corrective actions have been implemented for the identified residents? The following action items were implemented immediately on [DATE]. CR #1 died on [DATE]. On [DATE] an audit of Fall Risk Assessments was completed. Any resident who was identified as being at high risk for falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. 2. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? An in-service was initiated with licensed nurses on [DATE], by the Director of Nursing/designee, on implementing timely interventions post fall to include transfers to the hospital as indicated by the resident assessment. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed An in-service was initiated with licensed nurses on [DATE], by the DON/designee on immediately notifying the DON and/or Administrator of any falls with major injury such as a fracture. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed An in-service was initiated with licensed nurses on [DATE], by the DON/designee on neglect, to include falls with fractures. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed An in-service was initiated with licensed nurses on [DATE], by the DON/designee on reporting radiology results timely to the resident's nurse practitioner and/or physician when the results are received. The education included notifying the DON if the nurse practitioner and/or physician do not respond timely to the notifications. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in servicing is completed An in-service was initiated with direct care staff on [DATE], by the DON/designee on ensuring interventions are in place to prevent falls, including keeping a high-risk resident in an area that can be easily visualized by staff for safety when out of their room. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed An in-service was initiated with the Unit Managers, ADON, and MOS staff, by the DON on updating the care plan with new interventions timely after each fall. Any direct care staff member not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 36 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 in-serviced by [DATE] will not be allowed to work until the in servicing is completed Level of Harm - Immediate jeopardy to resident health or safety The Director of Nurses/designee will complete in-servicing on implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. Residents Affected - Few The DON/designee will in-service new hires during orientation on resident neglect, fall prevention and timely notification of radiology results to the physician and/or Nurse practitioner. CSD, DON and/or designee will complete one on one education with activity assistant and activity director that all residents who are at high risk for falls are not left alone when out of bed in an area that is not visible to staff. J. Educated/In-serviced nursing staff to notify the DON if X-Ray services do not respond in a timely manner. Monitoring: The Administrator, DON, ADON and Rehab Director will conduct random weekly checks, on all shifts, on the high risk fall residents or any new admits implementing timely interventions post fall, physician notification of radiology results, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by [DATE]. Any direct care staff member not in-serviced by [DATE] will not be allowed to work until the in-servicing is completed. For the next 30 days the DON and ADON will monitor the nursing staff per week given to determine retention of knowledge the universal fall precaution protocol. The results of these audits will be reviewed in the Quality Assurance and Performance Improvement meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. The QAPI Committee will continue to monitor monthly to identify any trends or patterns and make recommendations to revise the plan of correction as indicated. Surveyor Monitored the plan of removal as follows: Observations were started on [DATE] at different times, 8:30 AM, 9:30 AM, 11:00 AM, 2:30 PM, 3:30 PM, 4:30 PM, 5:50 PM, [DATE], 8:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM and continued through [DATE], 11:00 AM, 1:30 PM, 2:30 PM, 3:00 PM, 11:30 PM, 12:30 PM. Observations were started on [DATE] and continued through [DATE]. Observation of Resident ((#2, #3, #4, #5, #6, #7, #8, #9, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed bedrooms were free of clutter and adaptive devices were available for residents at risk for falls. Interviews were conducted on [DATE], [DATE], [DATE] with 23 with staff across all three shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS Coordinator A, CNA A, CNA B, CNA C, LVN A, LVN B, LVN C, LVNC, LVN D, LVN E, LVN F, LVN G, MA A, MA B, MA C,CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 37 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few LVN H and LVN I. All staff interviewed verbalized adequate understanding of plan of remove removal training received including Universal Fall Precautions policy/procedures, Kardex system, and Fall Prevention Procedures. Record review of the facility POR Binder revealed: Staff were in-serviced on [DATE], [DATE], regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls. Reporting, incidents, Kardex system and Fall Prevention Procedures. Reporting Radiology Results Timely. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights. Record review of QAPI sign-in sheet revealed the facility held a QAPI on [DATE] to discuss and implement corrective action for CR#1's fall. Record review of the following residents (#2, #3, #4, #5, #6, #7, #8, #9, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and CR #1) revealed Kardex Reports for residents at risk for falls had interventions in place to address falls. Record review of Kardex Binder revealed the facility had a binder at Nurse Station for halls #halls #1, #2, #3 and #4 Record review of the following residents (CR #1) #2, #3, #4, #5, #6, #7, #8, #9, #9, #10 and #11, #12, #13, #14, #15, #16, #17, #18, #19) revealed no care plans for residents at risk for falls. During an interview on [DATE] at 1:59p.m. with Regional RN said, she believes the facility currently has an IJ because of the resident's history of falls. She said the resident did not need a 1 on1 supervision, but because he had so many falls, it was a concern. She said when the residents are participating in activities, instead of staff taking residents back and forth, they should call for other staff members to come and get them. She said she wanted to make sure there is a system in place to move the residents back and forth to the activities area and that is a common area where other staff can see them. During an interview on [DATE] at 2:32p.m. the Administrator said, he believes the facility is currently has an IJ because there was a resident that fell and sustained a major injury. He said he has made sure that everybody understands how important it is to supervise residents. He said a big part of the morning meetings and meeting with quality assurance, is to make sure high-risk residents are always monitored. He said if there is a change in the environment, staff should know those changes and adapt to those changes. He said it is hard to do your job if you do not understand how to do certain things. He said he knows how staff is interacting with the residents by monitoring, walking around and observing what is happening on the floor and educating them with in-service trainings. During an interview on [DATE] at 1:33p.m. ADON said, she doesn't know why the facility has an IJ. She said she knew the incident that happened with the resident and that he had a fall. She said she was not working the day the resident had the fall. She said she could improve her work by being thorough with her documentation. She said all staff need to always monitor the residents at the facility. She said the fall risk residents she be around the nurse's station so that someone can keep a close eye on the residents. She said things would have gone differently if she was present at work during the incident with the resident. She said would have put interventions in place and care planned the falls based on how the falls happened. She said some of the trainings for staff are ongoing. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 38 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few said she had a broad view on how to care for the residents. She said the purpose of having in-service training is so that staff understands how to take care of the residents. She said things change and staff must continue to receive training to adapt to those changes. She said she knows that staff can do their job because she follows ups with them every day and she have has them to show her how to perform their job duties. During an interview on [DATE] at 1:42p.m. with RN, she RN she said the facility has an IJ because there was a resident with frequent falls, and they did not move to prevent him for falling and it resulted in his death. She said she learned that when they have a problem everyone has a problem. She said direct staff had a better idea for interventions that she does. She said she shared with the team that a resident had a fall. She said they went back and reviewed what was going on with the resident. She said for now on she is going to pay closer attention to the residents that are high risk for falls. She said the care plans will be closely directed to the resident. She said she will work closer with the activities director and document to show that the residents are being monitored. She said staff need to be educated and reeducated when things are ongoing regarding in-service. She said she would go back and ask questions to staff and have them to demonstrate on the computer what they are supposed to be doing to make sure they understand how to do their job properly. She said staff needs more training on how to create care plans. She said the care plans was not being done correctly since she has been at the facility. She said the care plans needs to be individualized. Record review of facility falls and fall risk, managing revised [DATE]: Policy Statement: Based on previous evaluations and current da[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 39 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician order for 1 (CR #1) of 20 residents reviewed for radiology services in that: Residents Affected - Few -The facility failed to report CR#1's ( Closed Record) x-ray results of a fracture of the left hip, femur, in a prompt manner. CR #1 fell on [DATE] at 2:00 PM, X-Ray done and NP got result on [DATE] and CR #1 transferred to hospital at 1:13 PM on [DATE] - CR #1 had a hip fracture that had delayed treatment which caused harm to the resident. This failure has the potential to place residents who receive diagnostic testing for delayed treatment and hospitalizations. Findings: Record review of CR #1 of face sheet revealed [AGE] year-old male, date of admission was [DATE] readmission on [DATE] died on [DATE] diagnosis included cerebrovascular disease (a disease of the heart or blood vessels), contusion (any collection of blood out a blood vessel) of eyeball and orbital tissues, unspecified eye, lack of coordination, muscle weakness ( Generalized), cognitive communication deficit, dysphagia (difficulty swallowing), oral phase, altered mental status, dementia (the loss of cognitive functioning, thinking, remembering, and reasoning-to such an extent that it interferes with a person's daily life and activities) unspecified severity, without behavioral disturbance, psychotic (when people lose some contact with reality) disturbance, mood disturbance and anxiety. Record review of CR #1's Quarterly MDS dated [DATE] revealed CR #1 had a BIMs score of 3 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of Progress Notes revealed CR #1 fell at the facility at 2:00p.m. on [DATE] and the x-ray was completed between 4:00p.m.-5:00p.m. On [DATE], his x-ray results came back at 9:55p.m. CR #1 was transported to the hospital on [DATE] at 1:13 PM. Record review of CR #1's of nurse's progress note revealed that a provider from OPTUM Health called for an update on the resident. Provider notified of radiological lab results and impression of the left hip, left femur, left knee, left tibia/fibula, left shoulder, left humerus, left elbow, left forearm. Record review of CR #1's Progress Notes dated [DATE] at 13:05 PM entered by LVN A Resident was picked by EMS via stretcher to be transferred to ER. Resident ate his lunch. Resident was calm and quiet. Paperwork was sent along with X-RAY results. RP and NP were notified of the transfer to ER. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 40 of 41 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 676059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082 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 0777 Level of Harm - Actual harm Residents Affected - Few Interview with the DON (Director of Nurses) on [DATE] at 11:14 AM, said resident CR#1 expired on [DATE], she said resident fell on [DATE] in the activity room, it was witnessed by another resident in the activity room because the activity assistant was busy transporting the resident to activity and there was nobody in the activity room. DON said the facility was remodeling the dining area where they always have activity. She stated that resident was trying to transfer from the wheelchair to a chair when he fell, X-ray was done, and resident was sent to the hospital. DON said LVN B did not notify on call NP of the impressions on the X-Ray and there were no new orders on [DATE]. Interview with Activity Director on[DATE] at 3:40 PM, she said she have been working in the facility for 5 years and they usually use dining room for activity or activity room at room at end of 300 hall always invite the residents for activity by assisting resident to activity room. Interview with the LVN A on [DATE] at 12:41 PM, LVN A said she was called to the activity room on 300 hall by a CNA. LVN A said she saw CR #1 lying on left side on the floor, CR #1 assessment was done. DON, NP and RP was notified. This occurred at the change of shift at 2:00 PM, LVN A said while assessing CR #1 lying on left side on the floor, CR #1 was saying ouch, ouch. She then assisted CR #1 to the wheelchair then transport him to his room. NP gave her ordered for X-Ray at about 2:30 PM. LVN A said she was not around when X-ray was done to CR #1. LVN A said an x-ray was ordered and it was done on 2p.m.-10p.m. shift. LVN A said CR #1 was totally dependent on staffs for transfer from wheelchair to bed and from bed to wheelchair, was cognitively impaired. Interview with Activity Assistant B on [DATE] at 1:05 PM, he said was transporting residents while CR #1 was in the activity room on 300 halls with other residents. He said CR #1 fell and they found him on the floor. LVN A was already checking CR #1 and was taken to the room. Activity assistant B confirmed that CR #1 was not able to ambulate, CR #1 was propelled by staff on the wheelchair. Interview with DON on [DATE] at 4:00 PM, regarding CR # waiting for 17 hours before transferring CR #1 to the hospital for left hip fracture, she said X-Ray company has to be called and depending on where they were that determines their response. DON said she was going to do in-services on notifying NP/MD. Record review of in-services done on [DATE] revealed DON had: Educated/In-serviced nursing staff to notify the DON if X-Ray services do not respond in a timely manner Record review of the facility policy dated 2005 (Revised [DATE]) for Lab and Diagnostic Test Result-Clinical Protocol: 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager or a telephone message to another person acting as the physician's agent ( for example, office staff). a. Facility staff should document information about when, how and to whom the information was provided and the response. This should be done in the progress notes section of the medical record and not on the lab results report because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 41 of 41