Health inspection·September 19, 2023

F 0686 Review of MDS dated [DATE] sections M0100 and M0300 revealed CR #1 had stage 4 pressure ulcers. Level of Harm - Immediate jeopardy to resident health or safety Review of care plan dated 7/20/2023 revealed resident (CR #1) had stage 4 pressure wounds with potential for further skin breakdown related to limited mobility. The goal, according to the care plan, was to ensure the pressure injury will show signs of healing and remain free from infection. The intervention was to Administer treatment as ordered and monitor for effectiveness. Assist resident with turning and repositioning during rounds. Residents Affected - Some Review of admission assessment on 05/23/2023 revealed resident had sacrum wound however, there was no detail assessment of the wound documented. Record review of wound care orders revealed the following: 05/23/2023 Stage 4 pressure wound sacrum full thickness: everyday shift Treatment order: Cleanse wound to sacrum with ns, pat dry and apply medi honey/alginate calcium and cover with dry dressing. 06/15/2023: Unstageable due to necrosis of right heel: everyday shift Treatment order: Cleanse w/ NS, pat dry, apply betadine to eschar on rt heel. Review of Treatment Administration Record (TAR) revealed there were no documentation of wound care provided for CR #1 on the following dates: 5/8/23, 5/13/23, 5/15/23, 5/16/23, 05/25/23, 06/02/23, 06/23/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23, 7/8/23, 7/11/23, 7/15/23, 7/17/23, 7/22/23, 7/23/23, 7/30/23, 08/21/23, 08/25/23. Further review of Treatment Administration Record revealed that wound care were not provided daily according to the physician's orders. Review of Weekly Skin assessment dated [DATE] revealed: Left heel pressure wound unstageable measuring 2.5cm x 2.5cm x 0.05cm. Right heel pressure wound unstageable measuring 5cm x 8cm x 0.05cm. Sacrum pressure wound unstageable measuring 7cm x 7cm x 0.3cm Review of Weekly Skin assessment dated [DATE] revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 2 of 14 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 09/19/2023 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 0686 Right heel pressure wound stage 4 measuring 5cm x 6.5cm x 0.05cm. Level of Harm - Immediate jeopardy to resident health or safety - Residents Affected - Some Further review of the Weekly Skin Assessments revealed the assessment conducted by the facility did not include descriptions of the pressure ulcers such as drainage, odor or general look of the pressure ulcer. Sacrum pressure wound unstageable measuring 10cm x 12cm x 0.2cm Review of Wound Care Doctor's note dated 08/29/2023 revealed: Stage 4 pressure wound of the right heel full thickness. Wound Size (L x W x D): 5.0cm x 6.5cm x 0.5cm. Surface Area: 32.50 cm². Exudate: Moderate Serous. Thick adherent black necrotic tissue (eschar): 80 %. Slough: 20 %. Wound progress: Not Improved. Primary Dressing(s):Hypochlorous acid solution (vashe) apply once daily for 30 days: Moisten gauze with Vashe and place over wound, followed by ABD, kerlix and tape. - Stage 4 Pressure wound sacrum full thickness: Objective Control Infection, Healing Wound Size (L x W x D): 10 x 11 x 0.2 cm. Surface Area: 110.00 cm². Cluster Wound open ulceration area of 88.00 cm². Exudate: Moderate Serous. Thick adherent black necrotic tissue (eschar): 70 %. Other viable tissues: 10 % (Dermis, SubQ). Skin: 20 %. Wound progress: Improved evidenced by decreased surface area Primary Dressing(s):Leptospermum honey apply once daily for 23 days: Use either the medi-honey gauze, or honey with calcium alginate.; Alginate calcium apply once daily for 23 days Review of Wound Care Doctor's note dated 08/22/2023 revealed: - Stage 4 pressure wound of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5.0 x 6.5 x 0.05 cm. Surface Area: 32.50 cm². Exudate: Moderate Serous. Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved. Primary Dressing(s): Leptospermum honey apply once daily for 30 days; Alginate calcium apply once daily for 30 days - Stage 4 pressure wound sacrum full thickness: Objective Control Infection, Healing Wound Size (L x W x D): 10 x 12 x 0.2 cm. Surface Area: 120.00 cm². Cluster Wound open ulceration area of 96.00 cm². Exudate: Moderate Serous. Thick adherent black necrotic tissue (eschar): 70 %. Other viable tissues: 10 % (Dermis, SubQ). Skin: 20 % (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 3 of 14 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 09/19/2023 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 0686 Wound progress: Not Improved. Level of Harm - Immediate jeopardy to resident health or safety Primary Dressing(s): Leptospermum honey apply once daily for 30 days: Use either the medi-honey gauze, or honey with calcium alginate.; Alginate calcium apply once daily for 30 days Residents Affected - Some Review of Wound Care Doctor's note dated 08/15/2023 revealed: - Unstageable (due to necrosis) of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5.0 x 6.5 x 0.05 cm. Surface Area: 32.50 cm². Exudate: None Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved Primary Dressing(s): Betadine apply once daily for 9 days: Apply Betadine to dry eschar, cover wound. Review of Wound Care Doctor's note dated 08/08/2023 revealed: - Unstageable (due to necrosis) of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5 x 6 x 0.05 cm. Surface Area: 30.00 cm². Exudate: None Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved Primary Dressing(s): Betadine apply once daily for 16 days: Apply Betadine to dry eschar, cover wound. Review of Wound Care Doctor's note dated 07/25/2023 revealed: - Unstageable (due to necrosis) of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5 x 6 x 0.05 cm. Surface Area: 30.00 cm². Exudate: None Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved Primary Dressing(s): Betadine apply once daily for 30 days: Apply Betadine to dry eschar, cover wound. Review of Wound Care Doctor's note dated 07/18/2023 revealed: - Unstageable (due to necrosis) of the right heel full thickness: Objective Control Infection Wound Size (L x W x D): 5 x 6 x 0.05 cm. Surface Area: 30.00 cm². Exudate: None Thick adherent black necrotic tissue (eschar): 100 %. Wound progress: Not Improved Primary Dressing(s): Betadine apply once daily for 9 days: Apply Betadine to dry eschar, cover (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 4 of 14 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 09/19/2023 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 0686 wound. Level of Harm - Immediate jeopardy to resident health or safety Record review of CR #1's blood sugar in the month of August 2023 was between 87 mg/dL to 476 mg/dL. Residents Affected - Some Review of progress note dated 09/01/2023 documented by Nurse I revealed CR #1 was sent to the hospital on [DATE] for change in condition. CR #1 was back to the facility same day. On 09/02/23 CR #1 was sent to the hospital again for change in condition. Progress note revealed resident (CR #1) to be clammy and pale in color vs obtained at 76/54-102-95.6-20-90% on room air. Resident with labored breathing, 911 was called to transport to hospital RP was notified of transport, on call NP notified of residents condition. Order obtained to send out to ER. Review of hospital record during CR #1's hospitalization starting on 9/02/2023 revealed: admission diagnoses: Septic Shock, UTI, osteomyelitis of right calcaneus, On 09/06/2023 Pre-procedure diagnosis: Right foot infection with osteomyelitis. Unstageable sacral and left gluteal decubitus. Procedure Performed: Right below knee amputation. Excisional sharp debridement of sacral and left gluteus. Findings: decubitus 14cm x 30cm x 1.5cm On 09/07/2023 at 3:08pm in an interview with the ADON who stated CR #1 was sent to the hospital because CR #1's hemoglobin level was low. She stated CR #1 was on antibiotic for infection and they were doing follow-up lab on her. The ADON stated when they did the lab, they discovered CR #1's hemoglobin was low, and they sent her to the hospital. The ADON was shown the TARs with the missed days of wound care, the ADON stated oh! My . she said she would find out what happened. On 09/19/2023 at 9:53am in an interview with the Wound Care Doctor, she stated she always saw all the residents with wounds every week. She said everything was going on well with CR #1 until August 29, 2023. She stated she evaluated CR #1's wound during wound care rounding on August 29th, and she noticed the wound on resident's right foot was not looking good and she cultured it. The Wound Care Doctor stated the result came back with infection according to how she suspected it. She stated the result came back with: Isolate (Aerobic, result 1): Proteus mirabilis isolated moderate ESBL on 08/31/2023. Isolate (Aerobic, result 2): Light growth Klebsiella pneumoniae isolated on 09/01/23. The Wound Care Doctor also stated the CR #1's pressure ulcer at the sacrum was not as big as it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 5 of 14 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 09/19/2023 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 0686 in the hospital. Level of Harm - Immediate jeopardy to resident health or safety On 09/08/2023 at 9:55am Surveyor observed CR #1 at the hospital the Family member, she stated the last time she changed her, the sore at the bottom was little. She stated recently, about two to three weeks ago (did not remember date) when she helped to turn the resident while still at the facility, she found the sore at the bottom was so big and she asked what happened. She said the DON was in a meeting and the other lady (she did not know name) she spoke with stated she should not worry that they would take care of her. Residents Affected - Some Resident #2 Review of face sheet revealed Resident #2 was a [AGE] years old male who was initially admitted to the facility on [DATE]. His current admission was on 03/08/2023 with diagnoses of quadriplegia, neuromuscular dysfunction of bladder, type 2 diabetes, osteomyelitis, pressure ulcer, essential primary hypertension, and anemia. Review of MDS dated [DATE] section M0100 and section M0300 revealed Resident #2 had stage 4 pressure ulcers. Review of care plan dated 06/14/2023 revealed Resident #2 had multiple pressure injuries with intervention to administer treatments as ordered and monitor for effectiveness. Record review of physician order for wound care revealed: 03/16/2023 Stage 4 pressure wound Sacrum full thickness: everyday shift Treatment order: cleanse sacrum wound with normal saline, pat dry, apply anasept, apply calcium alginate to wound bed, cover with dry dressing. 05/26/2023: Stage 4 pressure wound Left Ischium: cleanse wound with normal saline pat dry apply anasept/calcium alginate and cover with dressing daily 03/16/2023: Stage 4 pressure wound Right ischium: everyday shift Treatment order: cleanse with normal saline/ wound cleanser, pat dry, apply anasept to alginate calcium, cover with dry dressing Resident #2's Wound Care Doctor's note revealed the Following: 08/29/2023 - Stage 4 pressure wound sacrum full thickness: Objective Control Infection, Manage Exudate Wound Size (L x W x D): 8.2 x 7.0 x 1.0 cm. Surface Area: 57.40 cm². Exudate: Moderate Serous. Slough: 80 %. Granulation tissue: 20 %. Wound progress: Not Improved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 6 of 14 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 09/19/2023 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 0686 Primary Dressing(s): Alginate calcium apply once daily for 30 days; Santyl apply once daily for 30 days Level of Harm - Immediate jeopardy to resident health or safety 08/22/2023 - Stage 4 pressure wound sacrum full thickness: Objective Control Infection, Manage Exudate. Wound Size (L x W x D): 7.0 x 7.5 x 0.5 cm. Surface Area: 52.50 cm² Residents Affected - Some Exudate: Moderate Serous. Slough: 20 %. Granulation tissue: 80 %. Wound progress: Not Improved. Primary Dressing(s): Alginate calcium apply once daily for 9 days; Sodium hypochlorite gel (anasept) apply once daily for 16 days 08/15/2023 - Stage 4 pressure wound right heel full thickness: Objective Control Infection, Manage Exudate. Wound Size (L x W x D): 4.0 x 3.5 x 0.2 cm. Surface Area: 14.00 cm². Cluster Wound open ulceration area of 11.20 cm². Exudate: Moderate Serous. Slough: 20 % Granulation tissue: 30 %. Other viable tissues: 30 % (Muscle, Fascia, Tendon, SubQ). Skin: 20 %. Wound progress: Not Improved. Primary Dressing(s): Alginate calcium apply once daily for 16 days; Sodium hypochlorite gel (anasept) apply once daily for 23 days: Apply Anasept to subcutaneous tissue portion of the wound - Stage 4 pressure wound sacrum full thickness: Objective Control Infection, Manage Exudate. Wound Size (L x W x D): 7.0 x 7.2 x 0.5 cm. Surface Area: 50.40 cm². Exudate: Moderate Serous. Granulation tissue: 80 %. Other viable tissues: 20 % (Fascia, Muscle). Wound progress: Not Improved Primary Dressing(s): Alginate calcium apply once daily for 16 days; Sodium hypochlorite gel (anasept) apply once daily for 23 days - Stage 4 pressure wound of the right ischium full thickness: Objective Control Infection, Manage Exudate Wound Size (L x W x D): 7.5 x 3.0 x 1.1 cm. Surface Area: 22.50 cm². Exudate: Moderate Serous. Granulation tissue: 70 %. Other viable tissues: 30 % (Muscle). Wound progress: Not Improved Primary Dressing(s): Sodium hypochlorite gel (anasept) apply once daily for 23 days; Alginate calcium apply once daily for 23 days - Stage 4 pressure wound of the left ischium full thickness: Objective Control Infection, Manage Exudate. Wound Size (L x W x D): 4.5 x 2.5 x 0.2 cm. Surface Area: 11.25 cm² Periwound radius: Maceration. Exudate: Moderate Serous. Granulation tissue: 80 % Other viable tissues: 20 % (Muscle, Fascia, SubQ). Wound progress: Not Improved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 7 of 14 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 09/19/2023 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Primary Dressing(s): Alginate calcium apply once daily for 23 days; Sodium hypochlorite gel (anasept) apply once daily for 23 days: Apply Anasept to calcium alginate and place over wound Review of Treatment Administration Record revealed there was no documentation of wound care provided to Resident #2 on the following days: 04/08/23, 04/09/23, 04/11/23, 04/16/23, 04/23/23, 04/29/23, 04/30/23, 05/13/23, 05/15/23, 05/16/23, 05/18/23, 05/25/23, 06/09/23, 06/15/23, 06/21/23, 06/22/23, 06/28/23, 07/05/23, 07/07/23, 07/11/23, 07/17/23, 07/21/23, 07/22/23, 07/24/23, 08/21/23. Further review of Treatment Administration Record revealed that wound care were not provided daily according to the physician's orders. Review of progress notes revealed no documentation of wound care performed or attempts made to perform wound care for Resident #2 on the dates listed above. Review of Resident #2's census revealed Resident #2 was in-house from 03/08/2023 till the time of this investigation. Review of Physician note dated 05/11/2023 revealed Multiple open wounds .Wound culture pending. Preliminary report shows Mixed gram negative and gram-positive cocci isolated. Sensitivity report pending. Review of Physician note dated 05/17/2023 revealed Resident #2's wound culture to right buttock on 5/12/23 grew streptococcus and MRSA and Acinetobacter. Review of Physician note dated 08/31/2023 revealed the result of wound culture done on 08/30/23 showed heavy E.coli isolated ESBL. On 09/08/2023 at 5:12pm during observation and interview of Resident #2 in his room, he stated his wound got infected. He said he did not know how the wound was doing if it was getting better or not. He stated, well, I get wound care most of the time. On 09/17/2023 at 7:58am attempt to observe wound care to be performed on Resident #2, he declined to let Surveyor observe his wound, he said he was not comfortable with someone observing his wound. Resident #3 Review of face sheet revealed Resident #3 was initially admitted to the facility on [DATE] with diagnoses of type 2 diabetes, pressure ulcer, cerebral infarction,. atherosclerosis, hemiplegia and hemiparesis, hypertension. Resident #3's current admission was 05/22/2023 with new diagnoses of osteomyelitis of vertebral sacral region. Review of MDS dated [DATE] section M0100 through section M0300 revealed Resident #3 had pressure ulcers. Review of care plan dated 08/02/2023 revealed Resident #3 had pressure injuries to sacrum, left hip and right hip, with intervention to administer treatments as ordered and monitor for effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 8 of 14 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 09/19/2023 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Review of Treatment Administration Record revealed there were no wound care provided for Resident #3 for the following days: 08/25/23, 7/2/23, 7/5/23, 7/6/23, 7/7/23, 7/9/23, 7/10/23, 7/11/23, 7/17/23, 7/21/23, 7/22/23, 7/24/23, 7/31/23, 06/08/23, 06/21/23, 06/22/23, 06/23/23, 06/26/23, 06/28/23. Further review of Treatment Administration Record revealed that wound care were not provided daily according to the physician's orders. Residents Affected - Some Review of the Wound Care Doctor's note revealed the following: 08/29/2023 - Stage 4 pressure wound of the right hip full thickness: Objective Control Infection, Healing Wound Size (L x W x D): 2.0 x 2.5 x 0.7 cm. Surface Area: 5.00 cm². Exudate: Moderate Serous. Slough: 10 %. Granulation tissue: 80 %. Other viable tissues: 10 % (Muscle) Wound progress: Not Improved. Primary Dressing(s): Alginate calcium apply once daily for 30 days; Leptospermum honey apply once daily for 23 days 08/22/2023 - Stage 4 pressure Left hip full thickness: Objective Control Infection. Wound Size (L x W x D): 0.6 x 0.5 x 2.0 cm. Surface Area: 0.30 cm². Periwound radius: Mild erythema. Undermining: 4 cm. at 6 o'clock. Exudate: Moderate Serous. Other viable tissues: 100 % (Muscle, Fascia, SubQ). Wound progress: Not Improved Primary Dressing(s): Gauze packing strips (plain) 1/2 apply once daily for 30 days: Moisten with Vashe and pack into the wound.; Hypochlorous acid solution (vashe) apply once daily for 30 days. 08/15/2023 - Stage 4 pressure wound sacrum full thickness: Objective Control Infection. ound Size (L x W x D): 4.4 x 2.5 x 0.5 cm. Surface Area: 11.00 cm². Exudate: Moderate Serous. Slough: 10 %. Granulation tissue: 80 %. Other viable tissues: 10 % (Fascia, Muscle). Wound progress: Not Improved. Primary Dressing(s): Alginate calcium apply once daily for 9 days; Leptospermum honey apply once daily for 9 days Secondary Dressing(s): Foam w/border (silicone-sacrum) apply once daily for 9 days Peri Wound Treatment: Zinc ointment apply once daily for 9 days - Stage 4 pressure wound of the right hip full thickness: Objective Control Infection, Healing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 9 of 14 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 09/19/2023 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 0686 Wound Size (L x W x D): 2.0 x 2.0 x 0.3 cm. Surface Area: 4.00 cm². Exudate: Moderate Serous. Slough: 10 %. Granulation tissue: 80 %. Other viable tissues: 10 % (Muscle) Level of Harm - Immediate jeopardy to resident health or safety Wound progress: Not Improved. Residents Affected - Some Primary Dressing(s): Alginate calcium apply once daily for 16 days; Leptospermum honey apply once daily for 9 days Secondary Dressing(s): Gauze island w/ bdr apply once daily for 30 days Peri Wound Treatment: Skin prep apply once daily for 30 days 08/08/2023 - Stage 4 pressure Left hip full thickness: Objective Control Infection. Wound Size (L x W x D): 0.6 x 0.5 x 2.0 cm. Surface Area: 0.30 cm². Undermining: 4 cm. at 6 o'clock. Exudate: Moderate Serous. Other viable tissues: 100 % (Muscle, Fascia, SubQ). Wound progress: Not Improved. Primary Dressing(s): Gauze packing strips (iodoform) 1/2 apply once daily for 23 days: Pack wound daily with 1/2 iodoform gauze and cover with a dry dressing. Secondary Dressing(s): Gauze island w/ bdr apply once daily for 9 days Peri Wound Treatment: Skin prep apply once daily for 9 days Review of progress note revealed Resident #3 was sent out to hospital on [DATE] for peg tube placement. Review of hospital note dated 05/19/23 revealed Resident #3 was diagnosed with sacral osteomyelitis during the hospitalization. Review of Resident #3's census revealed resident was sent to the hospital on 5/13/2023 and came back on the 5/22/2023 On 09/08/2023 at 12:38pm in an interview with the Wound Care Nurse who stated she was working at the facility helping out with everything she said she was currently filling-in the position of the wound care nurse since the beginning of September 2023. She stated the Former Wound Care Nurse quit at the end of August 2023. She said if the wound care nurse was not here the floor nurses wound do the wound care. She said she documented all the wound care on TAR for all the care she had been doing since she became the wound care nurse. The Wound Care Nurse stated she was not sure if the Former Wound Care Nurse forgot to document on those days that wound care were missing on the TAR. She stated she was sure they were doing wound care and the Wound Care Doctor was always making rounding every week. On 09/08/2023 at 1:09pm attempt to call the Former Wound Care Nurse was made for interview. There was no response, the line stated, the person you are trying to reach is not accepting any call at this time . There was no prompt to leave voice message, but text message was sent. On 09/19/2023 at 11:57am, another attempt made to contact the Former Wound Care Nurse, but the line was 'saying' the same thing the person you are trying to reach . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 10 of 14 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 09/19/2023 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 09/08/2023 at 1:26pm in an interview with Nurse A, she said she had been working at the facility for two years, she said the facility had a wound care nurse. She said sometime if the wound care nurse was not in the building, it was the floor nurse that would be responsible for wound care. On 09/08/2023 at 1:33pm in an interview with Nurse B who was the assigned nurse for Residnet #3 on 100 hall on 06/08/23, 06/21/23, 06/22/23, 06/23/23, 7/6/23, 7/7/23, 7/10/23, and 08/25/23 when there were no documentation of wound care. She stated she could not tell why wound care was missed on those multiple days. She stated the treatment nurse was always in charge of wound care. She stated she had been working at the facility for four years, she did wound care sometimes in the past when the wound dressing came off and she documented in the TAR. She said there was always a wound care nurse in the building Monday to Friday, she stated if the wound care nurse was not in the building the nurses were to do wound care. On 09/08/2023 at 1:49pm in an interview with Nurse C, she stated she had been working at the facility for three weeks. She said she did not usually do wound care, because the facility had wound care nurse. She stated if the wound care nurse was not in the building the nurses would do the wound care. She said she did wound care only two times since she started working at the facility. She stated she had wound care training from her former job, but she never had any training or hands-on checklist at the facility. She stated they asked her if she knew how to do wound and she told them she could do wound care. On 09/08/2023 at 2:06pm in an interview with CNA B who stated she had been working at the facility for one month. She said they turn resident every two hours. She said she did not see or notice any outdated dressing on any resident. On 09/08/2023 at 2:11pm in an interview with Nurse D who had been working at the facility for three years. She said she did not usually do wound care, she stated only if the dressing came off. She said the Wound Care nurse was always at the facility doing wound care and the wound care nurse was responsible to do wound care at all times when the wound care nurse was in the building. She stated she did not know about how the wound care was missed on those, so she never had to do wound care. She said they turn resident every two hours; CNAs document the ADLs. She said they did train for her - said she watched video and they did check offs for her by the former DON. On 09/18/23 at 10:42am in an interview with Nurse L who had been working at the facility for about 8 years. He stated he had taken care of both CR #1 and Resident #2 in the past. He stated they have wound care nurse, but if there was no wound care nurse in the building, he said the nurses would do the wound care. He stated he sometimes he would do wound care for resident when the wound care nurse did not come to work. He stated they document in the elctronic system and that was where he documented his wound care. Surveyor asked about the days that he worked and there were no wound care documented on those days. He stated he was not aware of that and cannot say anything for it. He said when the wound care nurse was not in the building and he did wound, he always documented his wound care. He stated it is normally said if you don't document it is not done. On 09/08/2023 at 4:52pm in an interview with Nurse E who was working at the facility since 2020. She said she usually worked on 200 hall where Resident #2's room was located. She stated it was possible that she was working on those days (05/15/23, 05/16/23, 05/18/23, 05/25/23, 06/09/23, 06/15/23, 06/21/23, 06/22/23, 06/23/23, 06/28/23, 07/05/23, 07/06/23, 07/07/23, 07/11/23, 07/21/23, 07/24/23, 08/21/23) but she stated it had been a long time ago and she would not remember. She said if the wound care nurse was in the building, the wound care nurse wound do the wound and should document. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 11 of 14 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 09/19/2023 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some stated when she did PRN wound dressing change, if the dressing comes off or becomes saturated, she documented in the TAR. On 09/13/2023 at 4:02pm in an interview with the ADON about the wound care missing on multiple days. She stated, if you can't find it then I have no idea. The ADON stated the wound care nurse was responsible for the wound care and should document everything she did The ADON also said the DON was the supervisor over the wound care nurse to oversee what the nurses were doing. She said both the DON, the Administrator and the wound care nurse already quit, he said, they all quit at the same time. On 09/15/2023 at 10:43am surveyor called the Wound care Doctor but there was no response, message left on the voicemail. On 09/15/2023 at 10 45am Surveyor called the Attending Physician, the call went to voice message and there was no prompt to leave message. On 09/15/2023 at 10 48 am in an interview with the Nurse Practitioner who was working with the Attending Physician, he stated he worked with the Attending Physician and saw the residents (CR #1, Resident #2, and Resident #3) regularly. He stated they (Nurse practitioner and the Attending Doctor) consulted the wound specialist (Wound Care Doctor) to follow up with the treatment of the residents wound. He said they gave recommendations such as offloading, turning the resident every two hours, good nutrition/ hydration, and wound care order was also given by the wound care specialist. He stated it was up to the facility to make sure all these recommendations were being done. He stated he believed that the nurses were doing what the wound care Doctor recommended, he said the expectation was that the staffs at the facility followed the order. He stated, I am pretty sure that was done, but I am not there every single day He stated he was sure indication was given about the needed recommendation to care for the wound. He stated, if the order is there, the order will be followed up by the nursing staff, he stated, we gave the order. He said he had no idea that the wound care was not being done as no one told him that. Surveyor asked if the resident could be affected, if the wound could get worse if those recommendations (repositioning, offloading) and order for daily dressing change were not being followed. He stated, of course yes. He stated the recommendations were given so the residents wound did not get worse and if the recommendations were not followed the residents would be affected. Review of policy titled 'Charting and Documentation' dated July 2017 revealed, in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 12 of 14 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 09/19/2023 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 0686 d. Level of Harm - Immediate jeopardy to resident health or safety Changes in the resident's condition; Residents Affected - Some Events, incidents or accidents involving the resident; and e. f. Progress toward or changes in the care plan goals and objectives . 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting Review of policy titled pressure Ulcers/Skin Breakdown dated March 2014 revealed, in part, 1. The nursing staff and Attending Physician will assess and document an individual's significant risk fac-tors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 13 of 14 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 09/19/2023 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 0686 2. Level of Harm - Immediate jeopardy to resident health or safety In addition, the nurse shall describe and document/report the following: a.&n[TRUNCATED] Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 14 of 14