Health inspection·February 9, 2026

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 reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (CR #1) reviewed for supervision.The facility failed to provide sufficient supervision to CR#l on 01/31/2026 at 8:00pm, he was located at approximately 7:00 AM on 02/01/2026, approximately 7 miles from the facility, in the parking lot of a local Emergency Care Center. Upon discovery, CR #1 had sustained a laceration to his right eye, suspected to be from a fall. CR #1 required hospitalization from 02/01/2026 through 02/02/2026.These failures could result in residents not receiving appropriate supervision leading to elopement, injuries, hospitalization, or death.The noncompliance was identified as PNC. The noncompliance began on 01/31/2026 and ended on 02/02/2026. The facility had corrected the noncompliance before the survey began. Record review of CR #1 Facesheet revealed a [AGE] year-old male, was admitted on [DATE] with diagnoses including vascular dementia (block blood flow to your brain) and discharged from the facility on 02/01/2026 to local acute hospital. Record Review of CR #1's MDS dated [DATE] indicated that Resident #1 had a Brief Interview for Mental Status (BIMS), score of 9 out of 15, indicating moderate cognitive impairment. He had no behaviors, including wandering, and required partial/moderate assistance with transfers with ADLs. Record review of CR #1 physician order with order start dated of 01/16/2026 revealed CR #1 may go out on pass with medications. Record review of CR #1's comprehensive care plan initiated on 01/26/2026 did not include a care plan identifying CR #1 as an elopement risk prior to the occurrence of the elopement on discharge on [DATE]. Record reviewed of skilled nursing note dated, 01/28/2026 at 11:24pm noted no exit seeking behavior. Record review of CR #1 MAR revealed that medications were administered 01/31/2026 at 7:19pm. Further review revealed medication administered at 8:18pm by CMA A. Further review revealed no significant missed meds on 01/31/2026, after CR #1 was reported missing Record review of the facility entrance and exit log revealed no record that CR #1 had signed out nor notified staff of departure on 01/31/2026. Record review of CR #1 hospital record revealed in physician notes CR #1 was admitted to the hospital on [DATE] at 8:34am and discharged on 02/02/2026. Further review of record revealed RN from local ED searched patient's name and found a missing person's report from 1/31/2026. History was obtained from nursing facility and Cr #1's family member. Patient was initially placed in nursing home due to his difficulties with ambulation. However, he was able to ambulate with a walker of admission. On presentation to the ED, he was brought in by a local unhoused person who stated that she found him in the parking lot. At time he was cold, was bleeding from his right scalp and had minor lacerations to his bilateral hands. CT head negative for intracranial abnormalities, just showed right periorbital soft tissue swelling related to CR #1 fall/trauma Present on admission. infectious causes. Found to be dehydrated and hypotonic saline was administered. Patient medically optimized for discharge on [DATE].Record review of facility investigation evidence revealed CR #1 was located at approximately 7:00 AM on 02/01/2026, approximately 7 Page 1 of 4 676059 676059 02/09/2026 Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few miles from the facility, in the parking lot of a local Emergency Care Center. Upon discovery, CR #1 had sustained a laceration to his right eye, suspected to be from a fall. CR #1 required hospitalization from 02/01/2026 through 02/02/2026.Further review of the investigation evidence revealed the facility's immediate actions: The facility staff performed an immediate search of hall 200, the patient's room, and the patient's bathroom, followed by all adjacent halls, exits, and communal areas. Once it was noted that the patient was no longer in the facility, the exterior and perimeter of the facility, including the neighboring streets where checked, as well as the closet hospital to the facility The facility nurse supervisor notified the Administrator and DON that CR #1 had 8:30p.Within 30 mins of identifying that the patient was not in the immediate vicinity, a 911 call was made at 8:59p, and a missing person's report was filed, and an investigator was assigned to the case.The facility provided all necessary information, personal and clinical history, to the initial responding officers, as well as the assigned investigator, and a missing person's bulletin was provided.Facility staff performed a facility wide census and confirmed that all other facility residents were accounted for and safe.CR #1 's responsible party, was notified, along with the attending physician. Staff in-services related to the management of a patient elopement were initiated.Verified functioning of all facility doors was evaluated to ensure full operational. The time schedule for the door was verified and noted to be 7p as programmed.Staff searched for CR #1 until after midnight on 02/01/2026.The Administrator remained in contact with local police Investigator and received updates throughout the night on 01/31/2026.Elopement risk assessments for complete for all resident, and care plans were verified by the DON to reflect elopement risk. Interviews on 02/08/2026 at 12:13pm, the receptionist stated that there was front door coverage until 8:00 p.m. and all residents should be in account for by 8:00pm. The receptionist stated that she was required to seek coverage at the front desk if she had to take breaks. She stated that the front desk was not to be left unattended. She stated she was made aware of the CR #1 incident occurrence on 01/31/2026. She stated she had worked the day of the incident and recalled seeing CR #1 on earlier during the day, prior to her shift ending at 5:00pm. She stated she was informed that CR #1 had gone missing around 8:00pm after she had left for the day. She stated that since the incident on 01/31/2026. The facility changed the receptionist's hours (8:00am -8:00pm). She stated that she has been trained in elopement risk and management. She stated if a resident is identified as missing, she would first notify the house supervisor. Interview on 02/08/2026 at 12:36pm CR#1 pervious roommate stated he recalled seeing CR # 1 on 01/31/2026 evening, but he could not recall the time CR #1 left the room.Interview on 02/08/2026 at 12:50pm, Nurse A stated she was present at the facility on 01/31/2026. She stated she was not the primary nurse assigned to CR #1. She stated she was familiar with CR #1 and he did not have history of exit seeking behavior. She recalled seeing the resident sometime after dinner between 5:00pm and 6:00pm, but she did not recall seeing him exit the building. She stated an elopement code was implemented around 8:00 after being notified by other staff (she could not recall names) that CR #1 was missing. She staff all staff begin searching the facility and surrounding area for CR #1, who was not found prior to her shift end. She stated, a resident count was completed and verified no other residents had gone missing. She stated she believed CR #1 may have gone missing when 911 was called by another resident in the same hall (200 Hall). She stated she believe the receptionist shift ended at 5:00 on 01/31/2026 and the 9ll call by the resident happened after 7:00pm. She stated the facility had provided training on Elopement Response and she would notify the supervisor when first observed that a resident goes missing.Interview on 02/08/2026 at 1:00pm, the DON stated she was informed of the incident at approximately 8:30pm on 01/31/2026. She stated she was informed that staff had last seen CR #1 at 7:00 p.m. 676059 Page 2 of 4 676059 02/09/2026 Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few during medication rounds. The DON stated that she was aware that CR #1 was not compliant with signing in and out. The DON stated the receptionist was responsible for checking to ensure all residents and visitor sign in and out. The DON stated there was a receptionist at the front desk after from 8:00am - 8:00pm daily. She stated prior 01/31/2026 there was a receptionist for 8:00am - 5:00pm, but hour had since been extended and implemented on 02/01/2026 in the facility's response to CR #1's incident. She stated there should not be residents leaving the facility after 8:00pm and staff trainings had been provided on the recently implemented receptionist coverage. The DON stated there was no policy specifying how frequently staff should round on residents. She stated residents and their responsible party were educated on admission to them that residents were to sign out when leaving the facility on a leave pass. The DON stated that residents have the right to leave the facility when they like during identified pass hours. She stated it was the facility's responsibility for ensuring the safety and the account of resident leaving or returning. The DON stated that the facility ensured the account of a daily accurate census in the effort to monitor and account for residents. The DON said an elopement code was initiated during the incident as staff were unaware CR #1 had gone missing. The DON based on the facility's root analysis, it was likely that the resident exited the building on 01/31/2026, during a 911 emergency response to another resident. She stated first responders were present at the facility and the door was held open as they prepared another resident for transport. The DON stated staff were trained on elopement code and process on 02/01/2026, following the incident. She stated the facility had implemented a Resident Roster list that remained at the front desk with the receptionist, which identified residents needing assistance when exiting. She stated that direct care staff were made of aware of the list and how the list prevented future incidents form occurring. She stated staff were also educated on increased precaution during a 911 emergency response. She stated one staff member is to remain at the door entrance during after hour 911 emergency response.Interview attempt on 02/08/2026 at 1:13pm to CR #1's responsible party, left voicemail message requesting a follow up.Interview attempt on 02/08/2026 at 1:13pm to CR #1's responsible party, left voicemail message requesting a follow up.Interview attempt on 02/08/2026 via telephone at 1:30pm to CMA A (assigned to CR#1 on the date/time of incident), left voicemail message requesting a follow up.Interview attempt on 02/08/2026 via telephone at 1:38pm to CNA E (assigned to CR#1 on the date/time of incident), left voicemail message requesting a follow up. Interview on 02/08/2026 at 4:00pm, the administrator stated she was notified by the nursing supervisor on 01/31/2026 at approximately 8:30pm that CR #1 had gone missing and an Elopement Code was called. She stated she was informed that the facility staff performed an immediate search of hall 200, the patient's room, and the patient's bathroom, followed by all adjacent halls, exits, and communal areas. Once it was noted that the patient was no longer in the facility, the exterior and perimeter of the facility, including the neighboring streets where checked, as well as local hospital closet hospital to the facility. She stated a 911 call was made on 01/31/2026 at 8:59p, but facility continued the search for CR #1 until after midnight on 02/01/2026. She stated a missing person's report was filed, and an investigator was assigned to the case. She stated she remained in contact with local police investigator assigned. She stated CR #1's family was notified. She stated a facility audit of residents was continued on 01/31/2026 at approximately 9:00pm. She stated following the incident, in-services related to the Management of a patient elopement were initiated on 02/01/2026. The deficient practice occurred on 01/31/2026 and was corrected prior to the surveyor's onsite visit on 02/08/2026. The facility provided evidence that: Record review of facility's documented interview on 01/31/2026, time not recorded, CMA A stated she administered CR #1 evening medications at approximately 7:00 PM (time verified as 7:18p). 676059 Page 3 of 4 676059 02/09/2026 Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Following medication administration, she responded to other residents requesting assistance and continued medication pass. The Certified Nursing Assistant (CNA) assigned to CR #1 later notified her that the resident was not present in his room. An immediate search was initiated. According to her, the patient was not more confused than his baseline.Record review of facility's documented interview on 01/31/2026, time not recorded, CNA E she assisted the patient to the dining room for breakfast and lunch on the date of the incident. At approximately 6:30 PM-7:00 PM, she observed Cr #1 seated in a chair in his room while she was providing care to his roommate. She then exited the room to provide care to other residents. She is unable to recall the exact time, but shortly thereafter observed increased activity in the hallway related to another resident's room and briefly stopped to assist. When she later returned to CR #1's room, she noted that he was not present. She immediately notified other staff, and a search for the resident was initiated. When the CAN E was asked if the CR #1 was more confused than usual, she stated no.Record review of email from local police investigator confirmed that a 911 call was made by the facility on 01/31/2026 at 7:43 involving an emergency with another facility resident. Further review of record confirmed call was made by the facility on 01/31/2026 at 8:59pm to report that CR #1 was missing. Record review of facility incident record dated 01/31/2026 at 7:43pm confirmed another incident did occurrence, involving a 911 call, around the time the facility discovered CR #1 had gone missing.Record review of local police event history, confirmed police were called to report CR #1 as missing on 01/13/2026 at 8:59pm and police were dispatched at 9:02pm. An immediate facility-wide elopement risk reassessment was conducted on 02/01/2026.Staff received re-education on monitoring residents with cognitive impairment 02/01/2026.Door alarm systems were evaluated and tested.Monitoring rounds were reinforced during evening hours.No further incidents of elopement occurred after implementation of corrective actions.Record review of in service trainings: Receptionist In-service- Front Desk Expectations/Elopement Drill, dated 02/02/2026 General Staff In-service - Elopement Drill/ Managing patient elopement, dated 02/01/2026 and 02/02/2026Interviews on 02/08/2026 starting at 11:00am with staff, 3 CNAs (CNA Q, CAN L, and CNA, T,) and 3 Nurses (LVN L, LVN M, and LVN, J) revealed staff had been recently in-serviced on resident sign-in/sign-out procedures. The staff stated they conducted resident rounds every two hours and were required to call an Elopement Code for identified missing residents who could not be accounted for. All interviewed staff were familiar with the Resident Roster list, which identified residents needing assistance when exiting, and explained who was responsible for monitoring the front door. All interviewed staff stated they had previously provided care for CR #1 during is stay of 01/16/2026 - 01/31/2026. All stated that CR #1 did not demonstrate exit-seeking behaviors prior to the 01/31/2026. 676059 Page 4 of 4