Inspection·February 16, 2023

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 each resident receives and the facility provides food that is palatable and at an appetizing temperature for 7 of 21 residents reviewed for food and nutrition dietary services (Resident #32, #50, #52, #53, #55, #79, #88), in that: Residents Affected - Many ---(11) residents in a confidential group interview said the food was cold and not palatable when it was served ---residents said food was cold and not palatable when it was served and had no flavor This failure placed residents who ate meals in the dining room and in their rooms at risk of diminished quality of life and weight loss due to decreased food quality and temperature. Findings include: Record review of Resident #32's face sheet dated 2/16/23, indicated she was [AGE] years old and re-admitted on [DATE]. Her diagnoses included cerebral infarction (stroke), Type II Diabetes Mellitus (inability of pancreas to produce insulin to lower blood sugar), Acute Respiratory Failure (a disease or injury that affects your breathing), Zoster Encephalitis (inflammation of the brain caused by the viral infection Herpes Zoster), Anxiety (increase in fear or nervousness than normal), Hyperlipidemia (high levels of cholesterol), Acute Kidney Failure (kidneys suddenly stop working), Pneumonia (infection of the lungs), Major Depression (mood disorder causing persistent feeling of sadness and loss of interest), End Stage Renal Disease (kidneys reach advanced state of loss of function), Hypertension (high blood pressure), Charcot's Joint (weak joints that can dislocate easily in the foot). Record review of Resident #32's MDS dated [DATE], revealed a BIMS of 15 out of 15 indicating she was cognitively intact. On 02/14/23 In an interview with Resident #32 at 10:01 AM, she revealed the food was always cold. Their warmer was broken, so the food was cold when it got to you. She stated the warmer broke at least a month ago and the facility still had not received a new one yet. She said she had not made a grievance but had told some staff members about the cold food. Record review of Resident #50's face sheet dated 2/16/21revealed she was [AGE] years old and re-admitted on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (chronic obstructed airflow from the lungs), Pneumonia (infection of the lungs), Type II Diabetes Mellitus (inability of pancreas to produce insulin to lower blood sugar), Hypertension (high blood pressure), Morbid Obesity (being overweight that can cause health problems), Acute Respiratory Failure (a disease or injury (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 676073 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 676073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Quail Valley 2350 Fm 1092 Missouri City, TX 77459 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)