Inspection·February 2, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her room, yelled at her, and said she did not steal her charge and would not let her explain what she told CNA N. Unit Manager B said the facility monitored staff to prevent abuse was by in service on abuse. Unit Manager B said RA O was yelling at Resident #2 was a verbal abuse, and RA O was written up and suspended. During an interview on 02/01/24 at 2:29 p.m., RA O said she did not yell or argue with Resident #2, but when she gets emotional, her voice goes high, and she was crying because CNA N told her that Resident #2 said she stole her phone charger. RA O said she had been in serviced on abuse/neglect, and she knew yelling at any resident was verbal abuse. RA O said her voice may have been high, and it appeared as if she was rude, but she did not mean to disrespect Resident #2 and would not repeat it again. RO said she had not yelled at any resident before and she took very good care of her residents. During a telephone interview on 02/01/24 at 5:31 p.m., CNA N said Resident #2 told her to ask RA O if she had her phone charger because Resident #2 could not find it. CNA N said when she asked RA O if she took Resident #2's charger, RA O got upset and said Resident #2 said she stole her charger. RA O went into Resident #2's room, and she followed her. RA O was yelling at Resident#2. CNA N said RA O was hostile when she was asking why she told CNA N that she stole her phone charger and RA O was talking over Resident #2. CNA N stated the resident kept quiet because RA O continued to yell at Resident #2, and she was talking over Resident #2. CNA N was able to verbalize four types of abuse: verbal, physical, misappropriation of property, and sexual abuse. CNA N was able to state that the administrator was the abuse coordinator, and she had been in service on abuse/neglect for about two months. During an interview on 02/02/at 4:20 p.m., the DON said RA O should not have raised her voice or yelled at Resident #2. She said the resident could feel bad if the staff shouted at the resident. The DON said RA O was written up and suspended. The DON said the staff are monitored during abuse and neglect in service. The DON said none of the residents had reported to her RA O was abusive to them. Record review of the facility policy on abuse dated 2001 MED-PASS, Inc. (Revised December 2009) read in part . Policy Interpretation and Implementation . #2 . Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging . Record review of the facility in service on abuse and neglect dated 11/7/23 revealed RA O attended the in service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 2 of 10 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 02/02/2024 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)

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 7 residents (Resident #2 and Resident #3) reviewed for misappropriation. Residents Affected - Few The facility failed to prevent misappropriation of property when RA O and CNA M used Resident #2 and Resident #3's phone chargers and charged their phones. This deficient practice could affect any resident and could contribute to continued misappropriation of resident's property. Findings included: Record review of Resident #2's face sheet dated 02/02/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included hypertension (condition in which the blood vessels have persistently raised pressure), dementia (impair ability to remember, think, or make decisions that interferes with doing everyday activities), and quadriplegia (cannot control or move your muscles). Record review of Resident #2's quarterly MDS assessment, dated 01/09/2024, revealed a BIMS score of 13 out of 15, which indicated the resident's cognition was intact. Further review of Resident #2's MDS revealed the resident is dependent of staff for ADL care. Record review of Resident #2's undated care plan initiated 10/11/23 revealed: Resident #2 had an ADL self-care performance deficit related impair balance Interventions: encourage resident to use call bell to call for assistance. During an interview on 02/01/24 at 1:05 p.m., Unit Manager B said Resident #2 was upset and wanted to talk to her because RA O came and used her phone charger sometimes, and now she could not find it. Unit Manager B said it was never okay for RA O to use Resident #2 personal items. RA O should not have asked Resident #2's permission to use her phone charger; this would prevent any resident from losing their belongings. Unit Manager B said the administrator conducted in-service on abuse/neglect for staff, and not using resident property was part of the in-service, and that was how the facility monitored the staff. During an interview on 02/01/24 at 2:29 p.m., RA O said she used Resident #2 phone charger once, and it was Resident #2 who told her she could charge her phone with her charger, and she told Resident #2 that she would get into trouble. Resident #2 said she would tell them(management) that she was the person who told RA O to use her charger. RA O said she was aware she was not supposed to use Resident #2's phone charger because they had in service on abuse, and it included not using any resident property. RA O said that was why she was emotional when CNA N asked if she took Resident #2 phone charger because she would get into trouble. During an Interview on 02//01/24 at 2:59 p.m., Resident #2 said RA O had used her phone charger about three to four times in her room. Resident #2 said she felt uncomfortable when RA O used her charger, but she let her use the phone charger because she did not want to make her angry. When the surveyor asked Resident #2 why RA O would be angry with her, she did not respond. Resident #2 said when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 3 of 10 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 02/02/2024 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)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she could not find her phone charger, Resident #2 told CNA N to go and ask RA O if she had taken her phone charger because she had used it several times before in her room. Record review of Resident #3's face sheet dated 02/02/24 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #3 had diagnoses which included guillain barre syndrome (person immune system attacks the peripheral nerves), diabetes mellitus (elevated levels of blood glucose), and hypertension (condition in which the blood vessels have persistently raised pressure). Record review of Resident #3's quarterly MDS assessment, dated 01/04/2024, revealed a BIMS score of 11 out of 15, which indicated the resident's cognition was moderately impaired. Further review of Resident #3's MDS revealed the resident needed extensive assistance with ADL care with one to two staff assist. Record review of Resident #3's undated care plan initiated 02/17/22 revealed: Resident #3 had an ADL self-care performance deficit related autoimmune disease left hemiplegia. Interventions: encourage resident to use call bell to call for assistance. During an interview on 02/02/24 at 10:45 a.m., Resident #3 said CNA M came to his room about a month ago and asked if she could charge her phone with his phone charger, and he said yes because he did not want to upset her. Resident #3 said he said yes because he had his reasons and would not tell the surveyor why he said yes. Resident #3 said he felt safe in the facility. During an interview on 02/02/23 at 2:35 p.m., CNA M said she had previously used Resident #3's phone charger to charge her phone in Resident #3's room. CNA M said she had in-service on abuse/neglect, and she could not remember if using resident property was included in the training. CNA M said she was unsure if using resident personal property was right or wrong. During an interview on 02/02/24 at 4:20 p.m., the DON said the staff should not ask any resident if they could use their phone charger to charge their phones. The DON said the facility does in-service on abuse, including not using resident propertyies. The DON said RA O was written up by the ADON and suspended, but she was unaware CNA M used Resident #3's phone charger. Record review of the facility policy on abuse dated 2001 MED-PASS, Inc. (Revised December 2009) read in part . Policy Interpretation and Implementation .h . misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongs . without the resident's consent Record review of the facility in service on abuse and neglect dated 11/7/23 revealed RA O and CNA M attended the in service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 4 of 10 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 02/02/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one (Closed Record #1) reviewed for pharmacy services. 1. Unit Manager A failed to transcribe physician orders to administer Atorvastatin Calcium Oral Tablet 40 MG at bedtime for CR #1. These failures placed CR #1 at risk of not receiving full dosage and treatment of medication as ordered. Findings Include: Record review of CR #1's facility face sheet dated 12/1/2023 revealed a [AGE] year-old female with an initial admission date of 5/10/2023 and re-admission date of 11/8/2023. CR #1 had diagnoses to include Heart Failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side(paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis) (cerebral infarction, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and Dysphagia following cerebral infarction (Dysphagia is a swallowing disorder that may occur after a stroke), CR #1 was discharged on 11/15/2023. Record review of CR #1's admission MDS assessment dated [DATE], revealed that CR #1 had a BIMS (Brief Interview Mental Status score of 8, indicating CR #1 was moderately impaired cognitively and required extensive one-person assistance with ADL's. Record review of CR #1's care plan dated 5/14/2023 revised on 5/19/2023 revealed a care plan to address deficit in memory, judgement, decision making and thought process r/t CVA and CR #1's ADL Self Care Performance Deficit, requireing assistance with all ADLs dated initiated 5/12/2023, revised on 5/12/2023. Record review of CR #1's physician orders for June 2023 revealed an order for Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day related to other Hyperlipidemia, with a start date of 6/1/2023 and D/C date of 7/7/2023. Record review of CR #1's physician orders for July 2023 revealed an order for Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day related to other Hyperlipidemia, with a start date of 6/1/2023 and D/C date of 7/7/2023. Record review of CR #1's physician orders for August 2023 revealed no order for Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day related to other Hyperlipidemia. Record review of CR #1's physician orders for September 2023 revealed an order for Atorvastatin Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime related to other Hyperlipidemia, with a start (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 5 of 10 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 02/02/2024 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)

F 0755 date of 9/12/2023 and D/C date of 11/1/2023. Level of Harm - Minimal harm or potential for actual harm Record review of CR #1's physician orders for October 2023 revealed an order for Atorvastatin Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime related to other Hyperlipidemia, with a start date of 9/12/2023 and D/C date of 11/1/2023. Residents Affected - Some Record review of CR #1's MAR for June 2023 revealed that CR #1 was administered Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day on June 1, 2023 through June 30th, 2023 (a total of 30 consecutive days). Record review of CR #1's MAR for July 2023 revealed that CR #1 was administered Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day on July 1, 2023 through July 7th, 2023 (a total of 7 consecutive days). CR #1 was documented with an X on July 8th, 2023, through July 31,2023 indicating that CR #1 was not administered Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day as ordered by the physician for 24 consecutive days. Record review of CR #1's MAR for August 2023 revealed no order or administration of Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day Record review of CR #1's MAR for September 2023 revealed a check mark indicating that CR #1 was administered Atorvastatin Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime on September 12th, 2023, through September 30, 2023, as ordered by the physician. Record review of CR #1's MAR for October 2023 revealed an order for Atorvastatin Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime with a start date of 9/12/2023 and D/C date of 11/1/2023. A check mark indicating that CR #1 was administered Atorvastatin Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime on October 1,2023 through October 29th, 2023, as ordered by the physician. During an interview on 12/1/2023 at 12:43 pm, Unit Manager A. was asked who was responsible for discontinuing medication, she replied the nurses. She added the Nurse Practitioner of Physician writes the orders and when a medication was mistakenly discontinued, the nurse notifies the family. The interview also revealed that on 7/7/2023 she mistakenly did not transcribe the order to decrease the Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) to administer 10 mg when she received the order by the cardiolgist but did discontinue the physician order for Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium)-Give 1 tablet by mouth one time a day related to other Hyperlipidemia). She said the first-time I d/c'd the Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) was on 7/7/2023 and then I restarted it on 9/12/2023 per physician orders. Unit Manager A was asked what could be an outcome for a stroke and high cholesterol, she said the facility did labs again, lipid panel, an MRI of the head to see about stroke activity and according to RP, it was okay, all labs were okay and within normal range, This was an honest mistake.She said that the error was caught when the RP took CR #1 out for an appointment and noticed that the Atorvastatin was not listed on the medication sheet she had taken for the appointment. The RP returned to the facility on 9/12/2023 and notified the facility of the error. During an interview on 12/1/2023 at 2:25 pm with the DON, she was asked what negative outcome that could have beed caused by missing the Atorvastatin Calcium Oral Tablet 40 MG. She said the arteries could have clogged and possibly a stroke. When asked how do nurses manage meds? She said, we normally reconcile medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 6 of 10 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 02/02/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 12/1/2023 at 5:43 pm with CR #1's RP, she said that she talked to the ADON about her mom not getting atorvastatin for two months, and the ADON told her to come back. She called the doctor's office, they confirmed there was no discontinuation order for the Atorvastatin, CR #1 was supposed to continue the meds like the medical records said. She arrived at facility again around 4pm, and spoke to the ADON and the ADON sent Unit Manager A out to talk to speak to her, it was at this time, Unit Manager A said she was sorry, and she was the one who hit the discontinuation button for CR #1's medication. During an interview on 2/2/2024 at 12:07 pm with Unit Manager A, she said that she discontinued the physician order for Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) in error for CR #1. She added that this was revealed to her on 9/12/2023 by CR# 1's RP. When asked what type of negative outcome could not receiving the medication as ordered, she said that the facility ran labs and they were normal, she said there was no harm, she said she is not a doctor, she does not know. During a telephone interview on 2/2/2024 with Medical Doctor A, he said that he was aware that the physician order Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) was d/c'd in error for CR #1. He said he was notified by the facility and gave orders to run lab. The lab results were returned and within normal ranges. He said that he did not feel like the error caused any harm to CR #1. An interview on 2/2/2024 at 5:03 pm with the DON, she said that the medication and treatment policy that she provided was the only one that the facility had. Record review of the facility policy entitled Medication and Treatment Orders dated revised July 2016, read in part .Orders for medications and treatments will be consistent with principles of safe and effective order writing .orders must be recorded immediately in the resident's chart by the person receiving the order .Record review of the facility policy entitled Medication and Treatment Orders dated revised July 2016, read in part .Orders for medications and treatments will be consistent with principles of safe and effective order writing .orders must be recorded immediately in the resident's chart by the person receiving the order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 7 of 10 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 02/02/2024 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)

F 0760 Ensure that residents are free from significant medication errors. 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 residents were free of significant medication errors for 1 resident CR #1) reviewed for medication errors in that: Residents Affected - Some 1. The facility failed to ensure Unit Manager transcribed physician orders to administer Atorvastatin Calcium Oral Tablet 40 MG at bedtime for CR # These failures placed residents at risk of not receiving treatment of medication as ordered to treat medical diagnoses. Record review of the Medication Error Report dated 7/7/2023 read in part .Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day related to other Hyperlipidemia was d/c'd in error for CR #1;orders to run lab. Lipid panel lab results were returned and within normal ranges. NP notified . Record review of CR #1's facility face sheet dated 12/1/2023 revealed a [AGE] year-old female with an initial admission date of 5/10/2023 and re-admission date of 11/8/2023. CR #1 had diagnoses to include Heart Failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side(paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one?sided weakness, but without complete paralysis) (cerebral infarction, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) and Dysphagia following cerebral infarction (Dysphagia is a swallowing disorder that may occur after a stroke), CR #1 was discharged on 11/15/2023. Record review of CR #1's admission MDS assessment dated [DATE], revealed that CR #1 had a BIMS (Brief Interview Mental Status score of 8, indicating CR #1 was moderately impaired cognitively and required extensive one-person assistance with ADL's. Record review of CR #1's care plan dated 5/14/2023 revised on 5/19/2023 revealed a care plan to address deficit in memory, judgement, decision making and thought process r/t CVA and CR #1's ADL Self Care Performance Deficit, requireing assistance with all ADLs dated initiated 5/12/2023, revised on 5/12/2023. Record review of CR #1's physician orders for June 2023 revealed an order for Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day related to other Hyperlipidemia, with a start date of 6/1/2023 and D/C date of 7/7/2023. Record review of CR #1's physician orders for July 2023 revealed an order for Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day related to other Hyperlipidemia, with a start date of 6/1/2023 and D/C date of 7/7/2023. Record review of CR #1's physician orders for August 2023 revealed no order for Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day related to other Hyperlipidemia. Record review of CR #1's physician orders for September 2023 revealed an order for Atorvastatin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 8 of 10 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 02/02/2024 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime related to other Hyperlipidemia, with a start date of 9/12/2023 and D/C date of 11/1/2023. Record review of CR #1's physician orders for October 2023 revealed an order for Atorvastatin Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime related to other Hyperlipidemia, with a start date of 9/12/2023 and D/C date of 11/1/2023. Record review of CR #1's MAR for June 2023 revealed that CR #1 was administered Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day on June 1, 2023 through June 30th, 2023 (a total of 30 consecutive days). Record review of CR #1's MAR for July 2023 revealed that CR #1 was administered Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day on July 1, 2023 through July 7th, 2023 (a total of 7 consecutive days). CR #1 was documented with an X on July 8th, 2023, through July 31,2023 indicating that CR #1 was not administered Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day as ordered by the physician for 24 consecutive days. Record review of CR #1's MAR for August 2023 revealed no order or administration of Atorvastatin Calcium Oral Tablet 40 mg 1 tablet by mouth one time a day Record review of CR #1's MAR for September 2023 revealed a check mark indicating that CR #1 was administered Atorvastatin Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime on September 12th, 2023, through September 30, 2023, as ordered by the physician. Record review of CR #1's MAR for October 2023 revealed an order for Atorvastatin Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime with a start date of 9/12/2023 and D/C date of 11/1/2023. A check mark indicating that CR #1 was administered Atorvastatin Calcium Oral Tablet 40 mg give 40 mg by mouth at bedtime on October 1,2023 through October 29th, 2023, as ordered by the physician. During an interview on 12/1/2023 at 12:43 pm, Unit Manager A. was asked who was responsible for discontinuing medication, she replied the nurses. She added the Nurse Practitioner of Physician writes the orders and when a medication was mistakenly discontinued, the nurse notifies the family. The interview also revealed that on 7/7/2023 she mistakenly did not transcribe the order to decrease the Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) to administer 10 mg when she received the order by the cardiolgist but did discontinue the physician order for Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium)-Give 1 tablet by mouth one time a day related to other Hyperlipidemia). She said the first-time I d/c'd the Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) was on 7/7/2023 and then I restarted it on 9/12/2023 per physician orders. Unit Manager A was asked what could be an outcome for a stroke and high cholesterol, she said the facility did labs again, lipid panel, an MRI of the head to see about stroke activity and according to RP, it was okay, all labs were okay and within normal range, This was an honest mistake.She said that the error was caught when the RP took CR #1 out for an appointment and noticed that the Atorvastatin was not listed on the medication sheet she had taken for the appointment. The RP returned to the facility on 9/12/2023 and notified the facility of the error. During an interview on 12/1/2023 at 2:25 pm with the DON, she was asked what negative outcome that could have beed caused by missing the Atorvastatin Calcium Oral Tablet 40 MG. She said the arteries could have clogged and possibly a stroke. When asked how do nurses manage meds? She said, we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 9 of 10 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 02/02/2024 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)

F 0760 normally reconcile medication. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/1/2023 at 5:43 pm with CR #1's RP, she said that she talked to the ADON about her mom not getting atorvastatin for two months, and the ADON told her to come back. She called the doctor's office, they confirmed there was no discontinuation order for the Atorvastatin, CR #1 was supposed to continue the meds like the medical records said. She arrived at facility again around 4pm, and spoke to the ADON and the ADON sent Unit Manager A out to talk to speak to her, it was at this time, Unit Manager A said she was sorry, and she was the one who hit the discontinuation button for CR #1's medication. Residents Affected - Some During an interview on 2/2/2024 at 12:07 pm with Unit Manager A, she said that she discontinued the physician order for Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) in error for CR #1. She added that this was revealed to her on 9/12/2023 by CR# 1's RP. When asked what type of negative outcome could not receiving the medication as ordered, she said that the facility ran labs and they were normal, she said there was no harm, she said she is not a doctor, she does not know. During a telephone interview on 2/2/2024 with Medical Doctor A, he said that he was aware that the physician order Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) was d/c'd in error for CR #1. He said he was notified by the facility and gave orders to run lab. The lab results were returned and within normal ranges. He said that he did not feel like the error caused any harm to CR #1. An interview on 2/2/2024 at 5:03 pm with the DON, she said that the medication and treatment policy that she provided was the only one that the facility had. Record review of the facility policy entitled Medication and Treatment Orders dated revised July 2016, read in part .Orders for medications and treatments will be consistent with principles of safe and effective order writing .orders must be recorded immediately in the resident's chart by the person receiving the order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 10 of 10