Health inspection·January 31, 2024

F 0584 resident room. Level of Harm - Minimal harm or potential for actual harm In an observation of Resident #2's room on 01/31/24 at 10:18 AM, the following was revealed: the restroom had two small brown spots, that appeared to be feces, near the grab bar on the wall. The water in the commode was cloudy and full of feces remnants, while the rest of the bowl was covered in dried feces particles. A trash bag of soiled briefs was sitting on top of the trash can on the floor, between the right side of the sink and the toilet. Abed pan sat inside of a clear plastic drawstring bag hanging in between the left side of the sink and the wall. Residents Affected - Few In an interview with Resident #2 on 01/31/24 at 10:18 AM, she said she could not remember how long she lived at the facility. She said she used the toilet in her restroom to urinate and defecate every day. She said she had to have help from staff to get from her wheelchair to the toilet, and from the toilet back into her wheelchair. She said she could not remember the last time she used the restroom, but she thought it was today. She said she also wore briefs because sometimes she could not make it to the toilet to urinate. She said she did not know if the soiled briefs in the trash bag were worn by her. She said she did not know who put the trash bag in her restroom or where it came from. She said staff came by to clean her room every day. She said she did not think they cleaned her room today, but if they did not, somebody would come and do it. She said they (facility staff) knew her toilet was messed up . She said maintenance already came to fix the toilet. She said they (facility staff) told her when she put too much stuff in the toilet, that was what would happen . She said they (facility staff) told her to use the bed pan to take the water out of the toilet when it started to back up and get high. She said her toilet was backed up right now, but they (facility staff) fixed it. She said the toilet backed up and was fixed before but did not know when. In an interview with the Central Supply Coordinator on 01/31/24 at 10:22 AMShe said housekeeping had not cleaned resident rooms on the 300 hall yet. She said all staff were responsible for reporting maintenance issues. She said staff could use the computers to submit information, or notify maintenance verbally face to face. She said housekeeping cleaned all resident rooms each day. She said if any staff saw a toilet soiled with feces and a trash bag of soiled briefs in a resident's restroom, the staff was responsible for verbally notifying housekeeping, then housekeeping would address the situation immediately. She said she would notify housekeeping of the condition of Resident #2's restroom and ensure the situation was addressed. 2. Record review of Resident #4's face sheet dated 01/31/24, revealed he was an [AGE] year-old man admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy (metabolic issues {low or high glucose levels, low or high sodium levels, low thiamine level, low oxygen, low blood flow, high carbon dioxide levels, overabundance of fluid around the brain, kidney dysfunction or liver dysfunction} that cause brain dysfunction); Type 2 Diabetes with Hyperglycemia (blood glucose levels greater than 180 mg/dL one to two hours after eating in insulin resistant bodies); Chronic Pulmonary Disease (persistent or recurring inflammatory lung disease that causes obstructed airflow from the lungs); Dementia with other Mood Disturbances (loss of memory, language, problem-solving, and other thinking abilities severe enough to interfere with daily life and includes symptoms such as depression, anxiety, psychosis, agitation, aggression, disinhibition or sleep disturbances); and, Restlessness and Agitation (a sense of inner tension, irritability, fidgeting, finger tapping or other repetitive movements). Record review of Resident #4's quarterly MDS dated [DATE], revealed the resident's BIMS score was 3, which indicated severe cognitive impairment. Resident #4 used a wheelchair and walker; continuously exhibited disorganized thinking; impairments on the left and right side of his upper and lower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 2 of 4 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 01/31/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few extremities; required maximum assistance for toileting hygiene, bathing, dressing and personal hygiene; supervision for oral hygiene; and moderate assistance with eating. Record review of Resident #4's care plan revealed, he was a moderate fall risk related to confusion, hypotension, and impaired balance; had a goal to minimize/prevent the risk Septicemia related to an inability to control urination; was to be offered a bed pan as needed; received diuretic therapy; and bowel incontinence care during rounds as needed. Resident #4's care plan did not reveal a history of or interventions for the resident exhibiting behavior related to toilet use or urinating in the resident's room. Resident #4's progress notes did not reveal any incidents of the resident exhibiting behavior related to toilet use or urinating in the resident's room. In an interview with Resident #4 on 01/31/24 at 10:25 AM, he said he was okay and did not provide any further responses. In an observation of Resident #4's room on 01/31/24 at 10:28 AM, the following was revealed: the resident was in his restroom with the door closed. An area of the floor, approximately three feet long and 2 feet wide, beneath the residents bed was covered in dried dark urine . The rest of the room was free of clutter and clean. In an interview with the Central Supply Coordinator at 10:29 AM, she agreed the substance on the floor underneath Resident #4's bed was urine. She said she did not know if housekeeping had already cleaned rooms on the 100 hall. She said she would notify housekeeping Resident #4's room needed attention immediately . In an interview with the Administrator on 01/31/24 at 10:33 AM, he said he was not aware of any concerns regarding the cleanliness of resident rooms. He said he would check with the necessary staff to get more information about Resident #4's and #2's room and correct any issues. In an interview with the Administrator on 01/31/24 at 11:50 AM, he said he had been the administrator since 1/10/24. He said it was his expectation for staff to notify housekeeping and maintenance of emergency situations immediately, so they could be addressed as quickly as possible. He said the facility used an electronic system on all the tablets and computers accessible to all staff where they could log in and put in a work order for maintenance issues. He said if it was an emergency, the staff could also send a text message to the Maintenance Director. He said the housekeeping services were contracted out, but the Housekeeping Supervisor attended facility morning meetings and was very involved with what was happening in the facility. He said she also went behind housekeeping staff to observe and addressed any concerns with cleanliness in resident rooms. He said everyone needed to be more diligent about notifying the necessary staff to address situations like Resident #2's and Resident #4's. He said after addressing the incidents this morning, he was made aware Resident #2 and Resident #4 had similar incidents in the past. He said the facility would address the incidents by ensuring additional room checks and cleaning were implemented throughout each day for Resident #2 and Resident #4. In an interview with the DON on 01/31/24 at 12:01 PM, she said she has worked at the facility since 12/4/24. She said whatever microorganisms were present in the feces left behind in Resident #2's restroom could cause the resident to get an infection, or possibly e. coli (a group of bacteria that causes infections in the gastrointestinal tract, urinary tract and other parts of the body). She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 3 of 4 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 01/31/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #4, or the staff might have been prone to a fall, due to the urine on the floor in Resident #4's room. She said if Resident #4 encountered the urine he would have been at risk of an infection, based on whatever microorganisms that may have been present in the urine at the time of contact. In an interview with the DON on 01/31/24 at 2:44 PM, she said she wanted to share that both Resident #2 and Resident #4 were care planned for exhibiting behavior related to toileting. She said Resident #4 often spread her feces in places like her restroom and in her bed. She said Resident #4 urinating in his bed was a constant thing because he was bladder incontinent. She said Resident #4 was supposed to have a bed pan on his bedside table as an intervention. Record review of the policy, revised 09/05/2017, titled, Bathroom Cleaning revealed the following: DRY Steps: 1. Pull trash. Wipe can and if necessary replace liner . WET Steps: .5. Sanitize commode, tank, bowl & base . 6. Spot Clean - Walls . Additional information: Proper cleaning prevents the spread of infection . Record review of the policy, revised 09/05/2017, titled, Daily Patient Room Cleaning revealed the following: .5. Damp mop floor with germicide solution . Every room to be cleaned is that resident's home - Treat it as such . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676059 If continuation sheet Page 4 of 4