Health inspection·December 22, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in chunks. The draw sheet and the flat linen was soaked with urine and the room had ammonia odor. When CNA J was pulling the incontinent brief from under Resident #80 the brief broke apart and the fillings fell off on the sheet. During an interview on 12/21/23 at 11:57 a.m., CNA J said she had not changed Resident #80 since she came to work this morning between 6:30 a.m. and 7:00a.m. because she had to get residents up for breakfast. CNA J said after breakfast, she had to shower some residents. CNA J said she was in the middle of a shower for a resident when she saw Resident #80's light . CNA J said she went and told Resident #80 she had to wait until she finished showering the resident. CNA J said she was supposed to make rounds every two hours but did not because she was busy. CNA J said Resident #80's incontinent brief, flat sheet, and draw sheet were soaked with urine, and the cotton filler was broken apart and on the flat sheet when she was removing the brief from under Resident #80. CNA J said if Resident #80 was left wet for a long time, Resident #80 could have skin breakdown. CNA J said she had in-service and skills check-off for incontinent care. CNA J said the charge nurse monitors the aides When she makes random rounds. During an interview on 12/21/23 at 2:54 p.m., the ADON said CNA J should have made rounds every two hours for incontinent care for Resident #80. The ADON said if Resident #80 was left seated on an incontinent brief that was saturated with urine Resident #80 could have a skin breakdown and UTI (urinary tract infection). The ADON said the nurse monitored the aides to make sure they were providing care appropriately, and the unit manager and ADON monitored the nurse when they made random rounds. During an interview on 12/21/23 at 3:27 p.m., the DON said CNA J should have made rounds every two hours and as needed and provided care for Resident #80. which would have prevented Resident #80 from lying on a wet incontinent for extended hours, which could cause skin breakdown and infection. Record review of the facility policy on perineal care dated 2001 MED - PASS, Inc. (Revised October 2010) read in part . The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 2 of 8 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 12/22/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 4 residents (Resident #87, Resident #27, and Resident #80) reviewed for incontinent care. The facility failed to ensure Resident #87's privacy bag, foley bag and tubing were not placed on the floor. The facility failed to ensure Resident # 27's privacy bag, foley bag and tubing were not touching the floor, and LVN O followed appropriate procedure and infection control during foley care for Resident #27. The facility failed to ensure CNA J cleaned Resident #80 completely during incontinent care. These failures could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Resident #87 Record review of Resident #87's face sheet dated 12/21/23 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE]. Resident #87 had diagnoses which atrial fibrillation (irregular and often very rapid heart rate), benign prostatic hyperplasia(condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and hypertension(a condition which the blood vessels have persistently raised pressure) Record review of Resident #87's 5-day MDS assessment, dated 10/28/23 revealed: Resident #87 revealed BIMS of 03 indicated severely impaired cognation Resident #87's functional status revealed he required limited assistance with bed mobility, transfer, dressing, bath, and personal hygiene. Resident #87 was frequently incontinent of bowel and had foley. Record review of Resident 87's care plan initiated 11/17/23 revealed the resident had indwelling catheter Intervention: Change catheter as indicated, check tubing for kinks each shift. Record review of Resident #87's December 2023 order summary report read foley catheter 16 - FR - 10 cc bulb to bedside drainage, diagnosis: acute kidney failure active date 11/17/23. During observation and interview on 12/20/23 at 9:21 a.m., revealed that Resident #87's privacy bag was lying on the floor and that half of the foley and tubing were on the floor, too. Resident # 87 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 3 of 8 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 12/22/2023 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 0690 was not able to state why or how long the bag and tubing had been on the floor. Level of Harm - Minimal harm or potential for actual harm During observation and interview on 12/20/23 at 9:22 a.m., the Treatment nurse said the privacy bag, foley bag, and tubing were on the floor. The treatment nurse picked up the privacy bag, placed the Foley bag back into the privacy bag, hung the bag on the bed frame, and walked out of the room. Residents Affected - Some During an interview on 12/20/23 at 12:18 p.m., The treatment nurse said she should have changed the Foley bag and the privacy bag before she hung it back on the bed frame. She said the germs on the floor could have gotten on the bags and tube, and if the germ came into contact with Resident #87, he could have an infection. During an interview on 12/20/23 at 4:30 p.m., the Unit manager said Resident #87 foley bag and tubing should not be on the floor to prevent Resident #87 from getting UTI. The Unit manager said she monitors the nurse while the nurse monitors the aides to prevent the bags and tubing from touching the floor. During an interview on 12/21/23 at 2:36 p.m., the ADON said Resident #87 Foley should be hung on the side of the bed by the nursing staff, and when in W/C, the aides should hang the Foley bag on the side of the W/C. The ADON said it was inappropriate for the Foley bag, tubing, and privacy bag to be on the floor. The ADON said the treatment nurse should have changed the Foley bag, tubing, and privacy bag to prevent the germs from traveling into Resident #87's bladder and causing a UTI. The ADON said the clinical staff should monitor residents with Foley. Resident #27 Record review of Resident #27's face sheet dated 12/21/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #27 had diagnoses which included neuromuscular dysfunction of bladder (lack of bladder control due to a brain, spinal cord or nerve problem), diabetes mellitus(disorder in which the body does not produce enough or respond to normally to insulin) and hypertension(a condition which the blood vessels have persistently raised pressure) Record review of Resident #27's quarterly MDS assessment, dated 12/09/23 revealed: Resident #27 revealed BIMS of 13 indicated intact cognation Resident #27's functional status revealed she required limited assistance with bed mobility, transfer, dressing, bath, and personal hygiene. Resident #1 was incontinent of bowel and had foley. Record review of Resident 27's care plan initiated 09/29/23 revealed the resident had indwelling catheter related to obstructive uropathy. Intervention: change catheter as ordered, position catheter bag and tubing below the level of the bladder. Record review of Resident 27's Licensed Nurse MAR dated for December 2023 read Foley catheter 16 FR 10 CC bulb to bedside drainage, diagnosis: urine retention start date 09/28/23. During an observation and interview on 12/20/23 at 12:02 p.m., revealed Resident #27's Foley bag, privacy bag, and tubing were touching the floor. Resident #27 said CNA J came and lowered her bed about an hour ago, and maybe that was when her Foley touched the floor. Resident #27 said she could not see the Foley touching the floor. During an observation and interview on 12/20/23 at 12:03 p.m., LVN O said she observed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 4 of 8 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 12/22/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some #27's Foley privacy bag, Foley bag, and Foley tubing were touching the floor. LVN O elevated the bed, which prevented the Foley from touching the floor. LVN O said the bags and tubing had been contaminated, and the germs could go up to Resident #27's bladder, and she could have a UTI. LVN O said she should have disinfected the privacy bag and tubing or changed the Foley bag. During an interview on 12/20/23 at 12:11 a.m., CNA J said she did not know Resident #27's Foley bag, privacy bag, and tubing were touching the floor. CNA J said it was an infection control issue because the foley bags and tube had been contaminated, and Resident #27 could get an infection. CNA J said she had a skills check-off on Foley care. CNA J said the nurse monitored the aides when the nurse made random rounds. During an interview on 12/20/23 at 12:25 p.m., LVN O said she said she should have disinfected the privacy bag and tubing or changed the Foley bag for Resident #27 to prevent the spread of germs from the floor instead of elevation the bed with the contaminated Foley bags and tubing. LVN O said she had in-service and a skills check-off on working with a resident with Foley. During an observation on 12/20/23 at 2:05 p.m., LVN O and the Unit Manager provided Foley care for Resident #27. LVN O placed the Foley bag on the bed between Resident #27's legs for 10 minutes while LVN O provided Foley care for Resident #27. During an interview on 12/21/23 at 2:31 p.m., LVN O said she placed the Foley bag on the bed while she provided Foley care for Resident #27. LVN G said it was infection control issue because the urine would flow back into Resident #27's bladder, and the resident could get an infection. LVN O said she had a skills check-off for a resident who had a Foley. LVN O said the IP would monitor the nurses when she made random rounds. During an interview on 12/20/23 at 4:16 p.m., the Unit manager said LVN O placed the foley bag on Resident #27's bed during foley care, and she did not say anything to her because she thought she could not tell to put the foley below the bladder. The unit manager said the urine in the bag and tubing was going back to Resident #27 bladder, and it could cause UTI for Resident # 27. The Unit manager said she would be the person who monitored the nurses for Foley care, and she had not observed LVN O while she provided Foley care until today. Resident #80 Record review of Resident #80's face sheet dated 12/21/23 revealed a [AGE] year-old female admitted to the facility on [DATE].Resident #80 had diagnoses which included morbid obesity (weight is more than 80 to 100 pounds above ideal weight), anxiety disorder (an emotion characterized thoughts and physical changes), and hypertension (a condition which the blood vessels have persistently raised pressure) Record review of Resident #80's quarterly MDS assessment, dated 11/23/23 revealed: Resident #80 revealed BIMS of 13 indicated intact cognation Resident #80's functional status revealed she required extensive assistance with two staff assistance for bed mobility, transfer, dressing, bath, and personal hygiene. Resident #80 was incontinent of bladder and bowel. Record review of Resident 80's care plan initiated 09/06/23 revealed the resident was incontinent of bowel and bladder. Intervention: Check for incontinence during rounds; wash, rinse, dry perineum and change clothing PRN (as needed) after incontinence episodes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 5 of 8 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 12/22/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation of incontinent care on 12/21/23 at 11:01 a.m. revealed CNA J did not separate Resident # 80's labia when she provided incontinent care. During an interview on 12/21/23 at 12:08 p.m., CNA J said she did not separate Resident #80's labia during incontinent care. CNA J said if the labia were not separated and cleaned correctly, the area could have some germs, which could cause Resident #80 to develop UTI. CNA J said she had a skills check-off, which included peri care, and the floor nurse monitored the aides when the nurse made random rounds. During an interview on 12/21/23 at 2:54 p.m., the ADON said CNA J should have separated Resident #80's labia and cleaned properly (first cleaned left, right, and in the middle) to prevent infection, which could cause UTI for Resident #80. The ADON said CNA J should have had skills - check off before she started working on the floor. During an interview on 12/21/23 at 3:23 p.m., the DON said CNA J should have separated Resident #80's labia and cleaned left, right, and then in the middle. The DON said Resident #80 labia was not cleaned properly. The DON said it could harbor bacteria and cause infection for Resident #80. Record review of the facility policy dated 2001 MED-PASS, Inc. (Revised October 2010) read in part . The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . steps of the procedure #9b (1) . Separate labia and wash area downward from front to back . Record review of the facility policy dated 2001 MED-PASS, Inc. (Revised September 2014) read in part . The purpose of this procedure is to prevent catheter-associated urinary tract infections . maintaining unobstructed urine flow . 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 6 of 8 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 12/22/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 3 resident reviewed for dialysis services. (Resident #244) Residents Affected - Some The facility failed to consistently document Resident #244's dialysis communication form. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #244's face sheet dated 12/21/23 indicated Resident #244 was a [AGE] year-old female and admitted on [DATE] with diagnoses including thrombosis due to vascular prosthetic devices, implants and grafts, essential (primary) hypertension ( your blood is pumping with more force than normal through your arteries) end stage renal disease (is when you have permanent kidney failure that requires a regular course of dialysis or a kidney transplant) and dependence on renal dialysis (is a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to). Record review of Resident #244's admission MDS assessment dated [DATE] indicated Resident #244 was understood and understood others, adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #244 had a BIMS score of 12 which indicated moderately intact cognition. The MDS indicated Resident #244 received dialysis Monday-Wednesday- Friday. Record review of Resident #244's care plan dated 11/09/23 indicated Resident #244 needed dialysis (HEMO) related to renal failure. Intervention included monitor vital signs every shift and prn. Notify MD of significant abnormalities. Record review of Resident #244's dialysis communication forms reflected there were no dialysis forms for the following dates: 11/10/23, 11/13/23, 11/15/23, 11/17/23, 11/20/23, 11/22/23, 11/24/23, 11/27/23, and 11/29/23. Further review of the dialysis communication forms on Resident # 244's active chart reflected there were no information on the resident assessment and observation post-dialysis section for the following dates: 12/1/23,12/06/23, 12/08/23, 12/11/23, 12/13/23, and 12/20/23. During an interview on 12/22/23 at 9:48 AM, ADON A said the charge nurses filled out the top portion of the dialysis communication for before the resident left for dialysis. She said the nurse who accepted the resident back from dialysis was responsible for the bottom portion of the communication form. She said medical records scanned the forms into the resident's misc. section. She said the bottom portion was important to be filled to know any changes after dialysis treatment and the information is reported to the oncoming shift. ADON A stated she would check medical record office for Resident #244's dialysis communication form. During an interview on 12/22/23 at 10:00 AM, ADON A stated she checked medical records for Resident #244's dialysis communication forms and did not find the following dates: 11/10/23, 11/13/23, 11/15/23, 11/17/23, 11/20/23, 11/22/23, 11/24/23, 11/27/23, and 11/29/23. ADON A stated there were no forms scanned into the misc. section of the resident's active record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 7 of 8 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 12/22/2023 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 0698 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/22/23 at 10:19 AM, LVN A said when a resident returned from dialysis the communication form should be filled out with the resident's vital signs by the PM nurses. He said if the vital signs were not documented on the communication form, then some people put them in a progress note. He said the dialysis communication forms were placed in the medical record log and scanned into the resident's chart. Residents Affected - Some During an interview on 12/22/23 at 2:51 PM, the DON said the 2:00 PM to 10:00 PM shift nurse were responsible for filling out the information on the dialysis communication forms. She said the nurse assigned to the resident when they returned should fill out the bottom portion. She said it was important to obtain and document the resident's vital signs to make sure they are stable post dialysis. During an interview on 12/22/23 at 3:05 PM, LVN B said Resident #244 returned from dialysis before she started her shift. She said 2:00 PM to 10:00 PM were responsible to fill out the dialysis communication form when the resident return from dialysis. She said when the resident returned from dialysis, the resident's dialysis site should be checked for bleeding and check with resident to see if the resident ate. She said it was important to check vital signs and document on the communication form. She said not checking vital signs such as the blood pressure could risk not noticing complications. She said the resident could have low blood pressure, the dialysis site/port could need care, or the resident could not have eaten and become sick. She stated she missed checking the dialysis communication forms and had not called the dialysis center because the center would not return calls. She stated she had not reported the omitted forms to the ADON or DON. During an interview on 12/22/23 at 4:35 PM, the DON said she expected the nursing staff to fill out the dialysis communication form every day the resident received dialysis. She said nursing management should ensure this happened. She said the facility did not have a dialysis policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 8 of 8