Health inspection·May 22, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm 9:45 a.m., talking on the phone . then stated that the COTA stole $150.00 from my account. CR #1 showed DORS his bank account information on the phone with $50 and $100 Cash App withdrawals that were pending. The COTA told DORS that he never took money from CR #1's account, had used the phone to put music on CR #1's phone in the presence of CR #1 for less than a minute, and gave CR #1 his phone right back to him. The DORS wrote the statement on 02/07/2025 at 11:19 am. Residents Affected - Few Record review of CR #1's Life Satisfaction Survey/Incident Statement dated 02/08/2025, reflected, on 02/06/2025 at 8:00 p.m., Licensed Vocational Nurse (LVN) performed wound care in CR #1's room with the COTA in the room. LVN assisted CR #1 undressed his pants. The COTA placed CR #1's pants in a chair. In CR #1's pant pocket, CR #1 claimed was his bank card that was connected to his mobile phone. On 02/07/2025, during CR #1's therapy session, CR #1 worked with the COTA. The COTA asked CR #1 if he could play some music on CR #1's phone and CR #1 handed his phone over to the COTA. Three (3)-minutes after, CR #1 received a call from the bank requesting verification of a recent transaction and learning of transaction attempts with the COTA (first name only). CR #1 assured the bank the only the COTA (first name only) he knew was the COTA. CR #1 shared with DORS bank transaction screenshots showing attempted Cash App transfers and the facility began an n investigation, suspending the COTA in the interim. Record review of CR #1's statement dated 02/09/2025, reflected, on 02/06/2025, 8:30 p.m., LVN changed CR #1's brief in preparation of providing wound care on resident's backside. LVN took off CR #1 pants and asked the COTA to put them in a chair. The COTA placed the pants in a bag in the chair. CR #1's bank card was in the right-hand pocket of the pants. On 02/07/2025, The COTA took CR #1 to the therapy gym. CR #1 had been listening to music on his phone when the COTA asked could he play a song. The COTA returned the phone to CR #1 after 5-minutes and within 3-minutes thereafter, CR #1 received a call from his bank to verify cash transactions that were declined. CR #1 then asked the DORS to come look at the phone transaction and saw $220.00 worth of charges and said that the COTA was stealing his money. CR #1 was not happy with that the COTA. Record review of CR #1's Progress Notes dated 02/11/2025 at 03:26 p.m., reflected Social Worker (SW) met one on one with CR #1 who provided a statement regarding his unauthorized bank account cash transactions. SW assisted CR #1 with contacting his bank and obtaining a statement. CR #1 declined mental health services and declined to press charges. Record review of LVN's staff statement dated 02/11/2025, reflected that LVN entered CR#1's room on 02/06/2025 to perform a skin assessment. LVN noted that the CR #1 had bowel movement (BM) on his pants and assisted CR #1 to remove the pants and place in a plastic bag for CR #'s family to pick up. Record review of SW staff statement dated 02/11/2025, reflected SW, along with CR #1 contacted CR #1's bank, and spoke with a representative who informed CR #1 of the following: On 02/06/2025 at approximately 9:33 p.m. a transaction was initiated for $1.00 but later posted for $34.83 for gas at gas station. On 02/06/2025 at 10:52 p.m., a $0.00 Cash App was attempted from CR #1's banking institution. On 02/07/2025 at 08:51 a.m., a $0.00 Cash App was attempted from CR #1's banking institution. On 02/07/2025 at 08:52 a.m., a $200.00 Cash App was attempted from CR #1's banking institution and declined. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 2 of 12 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 05/22/2025 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 0550 On 02/07/2025 08:53 a.m., a $100.00 Cash App/transaction was successful. Level of Harm - Minimal harm or potential for actual harm On 02/07/2025 at 09:00 a.m., a $50.00 Cash App/transaction was successful. Residents Affected - Few Record review of CR #1's provider report dated: 02/14/2025 reflected, CR #1 spoke with a law enforcement officer and wanted to press charges against the COTA. As a result, CR #1 was offered psychological services which CR #1 refused. The facility confirmed that exploitation has occurred based on CR's bank's accounting showing the card was used while CR was admitted to the facility, however the facility had not been able to substantiate the COTA had been involved. Out of caution, the facility terminated the COTA. On 02/06/2025 CR #1 accused the COTA of stealing money from CR #1's account. SW visited with CR #1 to discuss his allegation of someone taking money from his account and offered psychological services, but he refused. The COTA had been interviewed and suspended pending the outcome of the investigation. Staff in-serviced on abuse prohibition and resident rights. On 02/14/2025, CR #1 that the COTA had stolen money from his account. Alleged perpetrator, the COTA interviewed and suspended pending the outcome of the investigation. During the investigation, it had been learned that CR#1's bank card had come up missing from CR#1's right pant pocket. Search of the room conducted with no bank card found. During interview with the CR #1 by the SW, they called the bank to discuss CR #1's account and were informed that there were 3-attempts to use CR #1's bank card with no outcome. However, on 02/06/2025 at 9:35 p.m. there had been a $1.00 charge at convenience store gas station and then a charge for $34.83 for gas at the same location. On 02/07/2025 at 8:53 a.m., there was a charge to CR #1's account for $100.00 via an online fund transferring app and another charge at 9:00 a.m. for $50.00 also via the online fund transferring app. The bank completed an adjustment credit for $150.00 back to CR #1's bank account. Law enforcement had been contacted on 02/06/2025 to ascertain if a police report could be filed, however, the officer shared that since the bank had credited the $150.00 back to the resident's bank account, there would be no police report filed. The Administrator (ADM) called the police department again on 02/11/2025 after it had been learned the attempts to withdraw money from the bank account and the charge for gasoline at the gas station. Investigation Findings: Confirmed. CR #1 continues to be monitored for psychological distress and staff continue to be in-serviced on abuse prohibition and resident rights. Record review of CR #1's skin assessment dated [DATE] at 4:07 p.m. reflected LVN performed CR #1 skin assessment. Record review of the COTA's hiring start date reflected he began his employment with the facility on 03/25/2024. Record review of the COTA's undated statement reflected, the COTA provided therapy services to CR #1 at 9:00 a.m. (on 02/07/2025). The COTA asked CR #1 to see his phone to play music for CR #1 for a total of 15-seconds while being beside CR #1. In an interview on 05/21/2025 at 10:33 a.m. the Director of Nursing (DON) stated the COTA used CR #1's phone to play music during CR #1's physical therapy session. CR #1 then accused the COTA of purchases made from CR #1's stored banking card on CR #1's cellphone. She stated that the COTA stated he had used CR#1's cellphone to play music but stated he had not made any purchases. She stated the bank returned CR #1's money and the COTA employment with the facility was terminated. In an interview on 05/21/2025 at 10:58 a.m., the ADM stated CR #1 had made a report that an individual with the first name as the COTA had made a purchase with CR #1's bank card at a gas station. He stated that CR #1 informed him that the COTA had access to his cellphone where CR #1's bank card (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 3 of 12 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 05/22/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few information was stored. ADM stated the CR #1 had been admitted at the facility at the time and date of the transaction and unable to transport to gas station to make the transaction. ADM stated that 3 to 4 miles had been the distance between the COTA's home address and the gas station. He stated he received screen shots from CR #1's phone reflecting electronic fund transfers from an app showed the COTA's first name as the receiver of the transactions. He stated that CR #1's had received a return on the transactions that were found to be unauthorized, and the COTA was suspended and automatically terminated as a result of the incident. In an interview on 05/21/2025 at 03:14 pm, SW stated she assisted CR#1 in contacting his banking institution to understanding the unauthorized banking transactions. An unsuccessful interview attempt was made on 05/22/2025 at 10:38 a.m. to the COTA. In an interview on 05/22/2025 at 10:44 a.m. CR #1 stated that on 02/05/2025 at 08:30 p.m. LVN came into his room with the COTA to attend to wound care on his buttock. He stated LVN took off his pants to perform the care passed the pants to the COTA to place in a bag on a chair. He stated at 3:00 a.m. he realized his bank card had been in pants that were in the bag placed by the COTA, but he went to the pants and found that the card had not been there. He stated that the COTA was the first staff to come in his room in the morning to take him to therapy. He stated he while in therapy, the COTA asked to play a song from his cellphone. He stated for 5 to 10 minutes the COTA had his cellphone. He stated then in the next moment, his financial institute called him regarding some suspicious activities. He stated he learned that 3-withdraw had been attempted the previous evening, a 4th attempt had been successful at a gas station in the amount of $45.00, and 3-Cash App withdrawals totaling $250 with a receiver's first name the same as the COTA. He stated screen shots of the Cash App transactions were captured by DORS. He stated the COTA denied any involvement, law enforcement were contacted. He stated while his banking institution returned the funds, he was upset, felt taken advantaged of and feared others may have fallen victim to the COTA. In an interview on 05/22/2025 at 11:19 a.m., DORS stated on 02/07/2025 at 08:30 a.m. CR#1 informed him that the COTA had stolen [NAME] money by making electronic withdraws from his cellphone to send funds through Cash App. He stated that the COTA denied making the transactions. He stated he reported the incident to the ADM and provided the ADM with screenshots he had captured of the transaction records on CR #1's cellphone. He stated that CR #1 and the COTA wrote statements. He stated at that time, he learned that on 02/06/2025, that the COTA had apparently stayed past his shift to assist LVN during CR #1's wound care when CR#1's bank card came up missing. He stated that the COTA should not have been in the CR #1's room helping LVN. He stated that the misappropriation of property left CR #1 very upset. He stated that the received an in-service on ANE performed by the ADON. In an interview on 05/22/2025 at 11:48 a.m., LVN stated that she was a treatment/wound-care nurse and on 02/06/2025, she stated that she had been employed with the facility since July of 2024 and worked Monday - Friday from 6:00 a.m. to 2pm and/or 8:00 a.m. to 5:00 p.m. depending on the needs of the facility. She stated that CR #1 had a surgical wound and on 02/06/2025 she was to have perform his initial wound assessment. She stated on 02/06/2025 was the first of meeting CR#1. She stated because she was not familiar with him or his size, as a precaution asked the COTA to assist in case CR#1 was a large resident requiring 2-person assist. She stated that CR#1 was dressed in a jogging suit when she entered his room and asked would he like a wear a gown during the assessment, but he declined. She stated she was able to pull down CR#1's pants to see his wound and then pulled them back up. She stated CR#1 had not required 2-person to assist and the COTA stood by and had not assisted. She stated she had not observed the resident's bank card nor the COTA placing or touching any of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 4 of 12 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 05/22/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's personal items or clothes. She stated she learned on 02/08/2025 during the morning meeting that CR#1 had a missing bank card and there was Cash App transactions that occurred with the COTA's name on it. She stated had she seen the bank card, she would have informed the resident and reported any suspiciousness to her manager. She stated she provided a verbal statement regarding the incident and had not spoken or seen the COTA since his employment ended with the facility. She stated she received abuse, neglect, and exportation (ANE) training all the time. Record review of 2 of 2 photographs taken by DORS with his phone of CR #1's phone screens reflected, a 02/07/2025 pending point of sale (POS) debit Cash App transaction in the amount of $50.00 and a second phone screens photograph reflected, a 02/07/2025 POS debit Cash App transaction in the amount of $100.00 showing the COTA's first name in asterisk. Record review of a 05/22/2025 navigation map reflected CR #1's bank card was used at a gas station that was 5.05 miles from the home address of the COTA and calculated 38.60 miles from the nursing facility. Record review of policy revise dated December 2016 titled Resident Rights Policy Statement reflected, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: 1. a dignified existence. 2. be treated with respect, kindness, and dignity. 3. be free from abuse, neglect, misappropriation of property, and exploitation. Record review of undated policy titled Reporting Abuse to Facility Management Highlights Policy reflected, Statement. It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors ., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Record review of in-service dated 06/24/2024 titled Abuse and Neglect, Resident's Rights . reflected the COTA signed off receiving training, conducted by ADON. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 5 of 12 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 05/22/2025 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 of misappropriation of property and exploitation for 1 of 2 residents Closed Record (CR) #1 reviewed for misappropriation and exploitation, in that: Residents Affected - Few 1. The facility failed to ensure the Certified Occupational Therapist Assistant (COTA) did not take CR#1's debit card without permission resulting in CR #1 losing $45.00. 2. The facility failed to ensure the COTA did not use CR #1's cellphone to access CR #1's banking information resulting $250.00 being taken from CR #1's account. These failures could affect residents and their responsible party by preventing them from having access to their funds. The findings included: Record review of CR #1's Facesheet dated 05/21/2025 reflected CR #1 was a [AGE] year-old male who admitted to the facility on [DATE], readmitted on [DATE], and discharged on 02/16/2025. CR #1's diagnosis included but were not limited to shortness of breath, sequelae of unspecified cerebrovascular disease (encompasses a variety of conditions that affect the blood vessels and blood supply to the brain, potentially leading to stroke and other neurological issues), atrial fibrillation (an irregular, often rapid heartbeat that originates in the heart's upper chambers), and malignant neoplasm of bladder (a type of cancer that develops in the bladder, the organ that stores urine). Record review of CR #1's discharge Minimum Data Set (MDS) dated [DATE] reflected he had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 reflecting the resident was cognitively intact. Record review CR #1' Occupational Therapy Treatment Encounter Notes dated 02/07/2025 at 01:37 p.m. reflected, COTA seen CR #1 seated in wheelchair. CR #1 engaged in 3x10 repetitions of bilateral, upper, extremity (BUE) exercises utilizing shoulder pulley machine, weighted dowel, and weighted therapy ball. Electronically signed by COTA. Record review of Director of Rehab Services (DORS) staff statement dated 02/07/2025, reflected: To Whom it May Concern. On Friday, 02/07/2025 at around 9:10 a.m. DORS saw CR #1 in the therapy gym performing his therapeutic exercises with COTA. When DORS returned from the morning meeting at around 9:45 a.m., CR #1 was still in the gym but on the phone talking with someone calm but serious. While going to DORS's desk, CR #1 then stopped DORS saying that he wanted to speak with DORS. DORS stopped for about a minute, but CR #1 was still on the phone, so DORS told CR #1 to come to DORS's desk when CR #1 was ready. After CR #1 got off the phone, CR #1 rolled himself to DORS's desk and stated that COTA stole $150.00 from my account. DORS immediately asked CR #1if he was sure because it was a serous accusation. CR #1 told DORS that he was sure and went on to show DORS his bank account on his phone with $50 and $100 Cash App withdrawals that were still pending. DORS called COTA to get COTA's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 6 of 12 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 05/22/2025 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 side of the story, and COTA told DORS that he never took money from CR #1's account. COTA stated that CR #1 asked COTA to put music on CR #1's phone, which COTA had done while in the presence of CR #1 for less than a minute and gave CR #1 his phone right back to him. DORS asked COTA to write a statement about the incident which COTA had done. DORS immediately reported the incident to the ADM on 02/07/2025 at 11:19 a.m. on 02/07/2025. Signed off by DORS. Residents Affected - Few Record review of CR #1's Life Satisfaction Survey/Incident Statement dated 02/08/2025, reflected, On Thursday 02/06/2025 around 8:00 p.m., CR #1 recalled Licensed Vocational Nurse (LVN) performing wound care and in his room was COTA. CR #1 recalled that LVN undressed his pants for they were soiled, received wound care. The soiled pants were passed to COTA and placed on the chair for family members to clean late. CR #1 opted for family to do his laundry opposed to the facility. In CR #1's pant pocket, CR #1 claimed was his bank card that was connected to his mobile for everyday use. On Friday 02/07/2025, during CR #1's therapy session, CR #1 was working with COTA. CR #1 prefers listening to music during his therapy sessions and COTA asked if he put on a [NAME] from CR #1's phone as they were working together. CR #1 paid no mind to this request and handed his phone over to COTA. Three (3)-minutes after his phone was returned to him, CR #1 received an alarming call from his bank concerning verification of a recent bank transaction. Left confused, CR #1 assured the bank he does not recall any recent bank transactions. Do you know COTA (first name only) The bank asked, and CR #1 assured them the only COTA (first name only) he knew was COTA who had been working with him. CR #1 reported to DORS and shared bank transaction screenshots showing attempted Cash App transfers. An investigation was conducted right away, and COTA was suspended for the day pending investigation outcomes. This report has been generated as part of the facility's Quality Assessment and Assurance process and constitutes confidential Quality Assessment and Assurance Committee Records. Record review of CR #1's statement dated 02/09/2025, reflected, On 02/06/2025, at about 8:to 8:30 p.m., LVN was in CR #1's room to change his brief and look at his backside for wounds. LVN stated that his pants were soiled she and COTA took off his pants and put them in a chair. CR #1 said to COTA put the pants in the bag so when CR #1's family came to take home. CR #1's bank card was in the right-hand pocket of the pants. This is where CR #1 put it when he went to bed. On the next morning COTA came into his room while he was eating. CR #1 told COTA he needed 5-minutes and COTA waited. COTA then pushed CR #1 down to therapy in a wheelchair. In the hall on the way to therapy, CR #1 was listening to music on his phone when COTA asked for the phone to play a song. After 5-minutes, COTA returned the phone and 3-minutes later CR #1 received a call from his bank to verify if CR #1 was the party trying to make cash transactions or someone else. CR #1 called the bank back and said he was not making those transactions. He had made a transfer a few days ago from savings to checking, but nothing else. The back said they would decline the transactions and to call for a new card. CR #1 informed back once he left the facility he would come get a new card. CR #1 then asked the DORS to come look at the phone transaction and saw $220.00 worth of charges and said that COTA was stealing from him. CR #1 was not happy with that . COTA working there and taking things was not right. Record review of CR #1's Progress Notes dated 02/11/2025 at 03:26 p.m. Social Service Note Late Entry: Social Worker (SW) met one on one with CR #1 and provided a statement regarding his account of someone using his credit card. SW assisted CR #1 with contacting his bank and obtaining a statement. (This is being addressed per policy). CR #1 currently does not want to receive any related mental health services at that time. SW informed CR #1 that if he changed his mind services would be available. No current related distress noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 7 of 12 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 05/22/2025 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 Record review of LVN's staff statement dated 02/11/2025, reflected that LVN entered CR#1's room on 02/06/2025 to perform skin assessment. LVN introduced herself as the treatment nurse and advised the CR#1 on what was about to be done, a skin assessment would be performed. LVN would look from head to toe to check to see if there were any wounds or discoloration to the skin. CR #1 verbalized understanding and gave permission for LVN to proceed to do the assessment. Upon performing the assessment, LVN noted that the CR #1 had bowel movement (BM) on his pants. LVN asked the CR#1 if she could take his pants off and put on a clean gown, so they could be washed. CR #1 stated that the LVN could take his pants off but place them in a plastic bag that had a few other clothing items in it, so the resident's family could do his laundry. LVN verbalized understanding and proceeded to do as CR #1 asked. LVN then cleaned the resident up from the BM that CR #1 had put on a clean brief as well as a clean gown. Then LVN proceeded to finish the head-to-toe assessment and once the treatment, LVN advised the CR#1 that the skin assessment was completed and if he had any questions. CR #1 replied, No, I am okay please turn the light out upon leaving. LVN turned the light out and proceeded out the door. All needs were met at that time. Signed off by LVN as the treatment/wound-care nurse. Record review of SW staff statement dated 02/11/2025, reflected SW, along with CR #1 contacted CR #1's bank, and spoke with a representative who informed CR #1 of the following: On 02/06/2025 at approximately 9:33 p.m. a transaction was initiated for $1.00 but later posted for $34.83 for gas at gas station. On 02/06/2025 at 10:52 p.m., $0.00 a bank transfer through a Cash App attempted to be sent to Cash App. On 02/07/2025 at 08:51 a.m. $0.00 was attempted to be sent to Cash App. On 02/07/2025 at 08:52 a.m. $200.00 was attempted to be sent to cash app/declined. On 02/07/2025 08:53 a.m. $100.00 was Cash App/transaction was successful. On 02/07/2025 at 0900 a.m. $50.00 was Cash App/transaction was successful. Record review of CR #1's provider report dated: 02/14/2025 reflected, CR #1 spoke with a law enforcement officer who stated he would come by the facility to speak with the resident and if the resident wanted to press charges, he would provide the necessary information to a Detective for further investigation. The officer had come to the facility and assigned a police report number and forwarded that information to a detective for further investigation. CR #1had been offered psychological services due to this incident, but he refused. The facility monitored CR for any signs or symptoms of distress. The facility confirmed that exploitation has occurred based on CR's bank's accounting showing the card was used while CR was admitted to the facility, however the facility had not been able to substantiate COTA had been involved. Out of caution, the facility terminated COTA. On 02/06/2025 CR #1 accused COTA of stealing money from CR #1's account. SW visited with CR #1 to discuss his allegation of someone taking money from his account and offered psychological services, but he refused. COTA had been interviewed and suspended pending the outcome of the investigation. Staff in-serviced on abuse prohibition and resident rights. On 02/14/2025, CR #1 that COTA had stolen money from his account. Alleged perpetrator, COTA interviewed and suspended pending the outcome of the investigation. During the investigation, it had been learned that CR#1's bank card had come up missing from CR#1's right pant pocket. Search of the room conducted with no bank card found. During interview with the CR #1 by the SW, they called the bank to discuss CR #1's account and were informed that there were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 8 of 12 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 05/22/2025 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 3-attempts to use CR #1's bank card with no outcome. However, on 02/06/2025 at 9:35 p.m. there had been a $1.00 charge at convenience store gas station and then a charge for $34.83 for gas at the same location. On 02/07/2025 at 8:53 a.m., there was a charge to CR #1's account for $100.00 via an online fund transferring app and another charge at 9:00 a.m. for $50.00 also via the online fund transferring app. The bank completed an adjustment credit for $150.00 back to CR #1's bank account. Law enforcement had been contacted on 02/06/2025 to ascertain if a police report could be filed, however, the officer shared that since the bank had credited the $150.00 back to the resident's bank account, there would be no police report filed. The Administrator (ADM) called the police department again on 02/11/2025 after it had been learned the attempts to withdraw money from the bank account and the charge for gasoline at the gas station. Investigation Findings: Confirmed. CR #1 continues to be monitored for psychological distress and staff continue to be in-serviced on abuse prohibition and resident rights. Record review of CR #1's skin assessment dated [DATE] reflected LVN performed an assessment on 02/06/2025 at 04:07 p.m. Record review of COTA's hire start date reflected a 03/25/2024 start date, and personal email, phone number and mailing address. Record review of COTA's undated statement reflected, Around 9:00 a.m. I was working with CR #1 for occupational therapy. After we finished our session, COTA was sitting with CR #1 . and mentioned music and what music had CR #1 liked. COTA used CR #1's phone to click on a music COTA liked. COTA used CR #1's phone and clicked on a song . COTA only had the phone for 15-seconds and CR #1 was right beside COTA. In an interview on 05/21/2025 at 10:33 a.m. the Director of Nursing (DON) stated that during a physical therapy session, CR#1 gave COTA his phone to play music, the resident then accused COTA of making a purchase from the credit card information stored on the resident's phone. She stated that COTA admitted having CR#1's phone to play music but denied the purchases. She stated COTA was terminated and CR#1's money had been returned by the bank. In an interview on 05/21/2025 at 10:58 a.m., the ADM stated CR #1 reported after CR #1' bank called him about an attempt to make a purchase by an individual's first name the same as COTA. He stated he looked at where the purchase at the gas station had been made in relation to COTA's home address and found it had been between 3 to 4 miles distance. He stated that the distance between the gas station and the NF was quite far, and CR #1 was admitted during the time and date of the transaction and could not have left to perform the purchase. He stated CR #1's cellphone screen shots of the electronic fund transfer app showed COTA's first name. He stated that CR #1's bank returned to unauthorized transactions. He stated based on the incident, COTA was suspended and automatically terminated. In an interview on 05/21/2025 at 03:14 pm, SW stated that she interviewed CR#1 after she learned of the unauthorized bank transactions occurred on CR #1's account. She stated that she assisted CR#1 in calling the back to understand what transactions transpired. She stated she could not recall off hand but had provided a written statement at the time of her knowledge of the misappropriation of property. An unsuccessful interview attempt was made on 05/22/2025 at 10:38 a.m. to COTA. In an interview on 05/22/2025 at 10:44 a.m. CR #1 stated that on 02/05/2025 at 08:30 p.m. LVN and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 9 of 12 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 05/22/2025 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 COTA came into his room to perform wound care on his buttock. He stated while removing and changing out his brief, bowel movement (BM) got on his pajama pants. The LVN noticed the BM and offered to assist him in changing his pants. He stated that LVN helped remove his pajama pants and he told her that he had clean pants in a bag that sat in a chair near his bed. He stated LVN asked him was it ok for COTA to go into the bag and remove the clean pants which he agreed. He stated COTA removed the clean pants from the bag and replaced them with the soiled pajama bottoms. He stated several hours later, he woke at 3:00 a.m. realizing that his bank card had been in the pajama pants that COTA placed in the bag. He stated he had the bank card in his pocket because he had purchased something offline and forgot to place it back into his wallet. He stated he scooted himself over to the chair and found that the card was not within the pants. Later that morning, COTA was the first staff member he seen of the day. He stated that COTA got him up and dressed and took him to the therapy gym. He stated he sat on an exercise machine listening to music from his phone through his ear buds. He stated while exercising, COTA asked him what kind of music he was listening to and asked could he see his phone to look for a song to play. He stated he gave COTA his phone and for nearly 5 to 10 minutes COTA had his phone before handing it back. He stated he continued exercising and moments later, his bank called informing him based on some suspicious activities that had occurred. He stated the bank informed him there were 3-withdraw attempts the previous evening from his missing bank card and on the 4th attempt a gas purchase in the amount of $45.00 had been made successful. He stated the bank then informed him that 3-Cash App withdrawals were made just moments before they called that triggered the suspicious activity prompting the call. The bank informed him the Cash App receiver had the first name as COTA. He stated while he was on the phone with the bank, he walked over to the Director of Rehabilitation Services (DORS) and told DORS that COTA had stolen his money and he needed to speak to the DORS when he finished his phone call. He stated he finished the call and informed DORS that COTA's name had just appeared on his phone from a Cash App transaction that trigged the bank to call him reporting suspicious activity. He stated he showed DORS the Cash App screen showing COTA's first name. He stated he then informed DORS about his missing bank card and how the night before COTA had assisted LVN during wound care and had placed his pajama bottoms containing the bank card in a bag during the care and informed DORS about the $45.00 gas transaction. He stated that DORS took a picture with is phone of the Cash App screens, showing 3-withdraw transactions in the amounts of $50, $100, and then another $100. He stated DORS then called COTA over and asked why his name appeared on the transactions, but COTA denied any involvement, stating he did not have the bank card. He stated that DORS informed COTA to write a statement. He stated that law enforcement had been contacted and he provided his statement. He stated that DORS asked that he not discuss what had transpired with any other residents or facility staff and stated that COTA had gotten off at 5:00 p.m. that evening and should not have even been in the room assisting LVN for wound care as that was not his job responsibility. He stated thereafter he never seen COTA again. He stated he spoke with the SW about pressing charges, but he declined since the bank refunded the gas and Cash App transactions. He stated he discharged home and had not heard anything further about the incident. He stated could not believe that it had occurred and was upset that COTA would take advantage of him. He stated he feared of how many others had been a victim of COTA. In an interview on 05/22/2025 at 11:19 a.m., DORS stated he had worked for the facility since 2017. He stated that on 02/07/2025 at 08:30 a.m. he had been sitting at the back of the gym where his office was and observed CR#1 with COTA exercising. He stated he then exited the gym to attend the facility's morning meeting and when he returned he observed CR#1 which appeared to be a serious phone conversation. He stated that CR#1 walked up to him and said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 10 of 12 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 05/22/2025 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 stated COTA stole my money. I need to talk to you. He stated that CR#1 finished he phone call, learning, with CR#1's bank and informed him that COTA had made electronic withdraws from his phone using his Cash App account. He stated that CR#1 showed him the transactions on his phone and asked could he take pictures to show the ADM. He stated that CR #1 agreed, and he showed the transactions to COTA showing COTA's first name. COTA denied any involvement. He stated he then contacted the ADM who spoke to COTA, and he wrote a statement and then was sent off shift until they could investigate the incident. He stated that CR #1 wrote statement and learned that on 02/06/2025, that COTA had stayed late and assisted LVN during wound care, and how CR#1's debit card had come about missing. He stated it was normal for COTA to stay a little late, but COTA should not have been in the CR #1's room helping LVN. He stated that CR#1 was very upset after the incident and told anyone who would listen about what had happened. He stated COTA worked for the facility from 03/25/2024 to 02/07/2025 Monday - Friday from 7:00 a.m. to 4/4:30 p.m. and had been a young, and always helpful staff, receiving many compliments from residents over the course of the employment. He stated he had been very surprised to learn of the situation. He stated that in-services were performed on ANE by ADON. In an interview on 05/22/2025 at 11:48 a.m., LVN stated that she was a treatment/wound-care nurse and on 02/06/2025, she stated that she had been employed with the facility since July of 2024 and worked Monday - Friday from 6:00 a.m. to 2pm and/or 8:00 a.m. to 5:00 p.m. depending on the needs of the facility. She stated that CR #1 had a surgical wound and on 02/06/2025 she was to have perform his initial wound assessment. She stated on 02/06/2025 was the first of meeting CR#1. She stated because she was not familiar with him or his size, as a precaution asked COTA to assist in case CR#1 was a large resident requiring 2-person assist. She stated that CR#1 was dressed in a jogging suit when she entered his room and asked would he like a wear a gown during the assessment, but he declined. She stated she was able to pull down CR#1's pants to see his wound and then pulled them back up. She stated CR#1 had not required 2-person to assist and COTA stood by and had not assisted. She stated she had not observed the resident's bank card nor COTA placing or touching any of the resident's personal items or clothes. She stated she learned on 02/08/2025 during the morning meeting that CR#1 had a missing bank card and there was Cash App transactions that occurred with COTA's name on it. She stated had she seen the bank card, she would have informed the resident and reported any suspiciousness to her manager. She stated she provided a verbal statement regarding the incident and had not spoken or seen COTA since his employment ended with the facility. She stated she received abuse, neglect, and exportation (ANE) training all the time. Record review of 2 of 2 photographs taken by DORS with his phone of CR #1's phone screens reflected, a 02/07/2025 pending point of sale (POS) debit Cash App transaction in the amount of $50.00 and a second phone screens photograph reflected, a 02/07/2025 POS debit Cash App transaction in the amount of $100.00 showing COTA's first name in asterisk. Record review of a a 05/22/2025 map navigation reflected that the gas station where CR #1's bank card was used on 02/05/2025 was 5.05 miles from the COTA's home address and 38.60 miles from the nursing facility. Record review of policy revise dated December 2016 titled Resident Rights Policy Statement reflected, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 11 of 12 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 05/22/2025 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 rights include the resident's right to: Level of Harm - Minimal harm or potential for actual harm 1. a dignified existence. Residents Affected - Few 2. be treated with respect, kindness, and dignity. 3. be free from abuse, neglect, misappropriation of property, and exploitation. Record review of undated policy titled Reporting Abuse to Facility Management Highlights Policy reflected, Statement. It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors ., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Record review of in-service dated 06/24/2024 titled Abuse and Neglect, Resident's Rights . reflected COTA signed off receiving training, conducted by ADON. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676073 If continuation sheet Page 12 of 12