Health inspection·September 15, 2022

F 0693 Level of Harm - Minimal harm or potential for actual harm be free pf aspiration through the review date. Target date 11/21/2022. Interventions included: Keep HOB elevated 30-45 degrees during and thirty minutes after tube feeding. Focus: Resident #84 has potential fluid deficit. Date revised on 11/13/2021. Goal: will be free of symptoms of dehydration and maintain moist mucus membranes, and good skin turgor. Target date 11/21/2022. Interventions included: Administer medications as ordered. Date initiated on 11/13/2021. Residents Affected - Few Record review of Resident #84's active Physician's order summary revealed an order to flush G-tube with 30 cc's water before and after medications, flush with 10 cc's water between medications, two times a day, start date 08/04/2022. Head of bed elevated at 30-45 degrees except to allow for ADL care, two times a day, start date 08/04/2022. Document total intake every shift to include formula and free water flushes, two times a day, start date 08/04/2022. Diet Order Summary: NPO diet, start date 08/03/2022. Apixaban tablet 5 mg, start date 08/03/2022; give 1 tablet via PEG-tube two times a day for blood thinner; Senna-Docusate sodium tablet 8.60-50 mg start date 08/04/2022, give 2 tablet via PEG-tube one time daily for constipation; Tamsulosin HCL capsule 0.4 mg, start date 08/04/2022; give 1 via PEG-tube one time a day for BPH (benign prostatic hypertrophy); Donepezil HCL 5 mg tablet, start date 08/04/2022; give 1 via PEG-Tube one time a day for dementia; Famotidine 20 mg tablet, start date 08/03/2022; give 1 tablet via PEG-Tube two times a day for GERD. During med pass observation on 09/14/2022 at 7:05 AM revealed LVN A prepared medications for administration via G-tube for Resident #84. LVN A prepared each of the medications (Eliquis, Donepezil, Famotidine, Tamsulosin, Senna) by placing each tablet/capsule into individual medication cups. He crushed the tablets individually and returned to medication cups. He placed the medication cups onto the bedside table. With clean gloves on he opened a Tamsulosin capsule and emptied the content into the med cup. He retrieved water from the bathroom sink and suspended the crushed medications in 10 ml (equivalent to cc's) of water to each cup and stirred with a wood spoon. Resident #84 was awake and observed lying in bed with the head of the bed less than 30 degrees. The tube feeding pump was already paused. LVN A disconnected the continuous tube feed. LVN A connected an empty 60 ml syringe to Resident #84's G-tube and aspirated(withdrew) a small amount of stomach contents. He disconnected the syringe and pushed the content of the syringe into the plastic graduated measuring cup. He drew the first diluted medication up into the syringe, connected the syringe to the G-tube and pushed the medication into the G-tube. He disconnected the syringe and removed the plunger, connected the syringe back to the G-tube and poured the second diluted medication into the barrel of syringe allowing gravity to fully infuse the medication. He repeated the process with each of the remaining 3 diluted medications. He disconnected the syringe, drew up 10-15 ml of water and push-flushed into the G-tube. He connected the tube feed to the G-tube and turned the pump back on to resume continuous feeding. LVN A cleaned up the supplies, removed his gloves and sanitized his hands. He raised the head of the bed to 30 degrees. In an interview on 09/14/2022 at 7:45 AM, LVN A stated the HOB should be 45 degrees to prevent aspiration. He stated he did not raise the HOB earlier because Resident #84 complained and did not want his head that high. He stated he checked placement of the G-tube before he started med pass with the surveyor. As LVN A checked the orders in computer, he stated the orders were to give 10 ml of water between each medication, but he did not and said he should have. He stated the reason for the water given between each medication was so the tube did not clog up. LVN A stated he poured each medication into the barrel of the syringe and denied pushing using the plunger. In an interview on 09/14/2022 at 3:30 PM, the DON stated the HOB should be at least 45 degrees to prevent aspiration when giving medications via G-tube. He stated 30 ml of water flush should be given before and after medication administration. He checked the orders for Resident #84 and confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 2 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the physician's orders. He stated the water flushes are for maintaining patency of the G-tube and to ensure the medications clear as it could clog the tube. He stated medications should be administered via gravity and that some nurses push using the syringe. He stated the benefit of infusing via gravity was to prevent injury to the resident and that trauma to the stomach could occur. He stated safe practice was to infuse via gravity. He stated the unit manager watches the nurses to ensure proper technique. He stated he knows Resident #84 does not want his head higher than about 35 degrees and that the resident has the right. In an interview on 09/14/2022 at 3:45 PM, Unit Manager A stated 30 to 40 ml water is given before and after medication administration. She stated she had told nurses to not be plunging the medications but to only use gravity. She said plunging is like force feeding and is abuse. She stated the HOB should be at 45 degrees, and if they lay the resident flat the meds/fluids could get into lungs. She said she will be re-educating the nurses on proper medication administration for G-tubes. Record review of the facility policy and procedure titled Administering Medications through an Enteral Tube, 2001 Med-Pass, Inc. (Revised March 2015), revealed: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Preparation: 1. Verify that there is a physician's medication order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident .General Guidelines .3. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately .6. Dilute medications and flush the tube with room temperature tap water .Steps in the Procedure .14. Assist the resident to semi-Fowler's position (30 deg [degrees] to 45 deg [degrees]) .21. When correct tube placement and acceptable GRV (gastric residual volume) have been verified, flush tubing with 15-30 ml warm sterile water (or prescribed amount) .24. Reattach spring (without plunger) to the end of the tubing. 25. Administer medication by gravity flow. A. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion .c. Clamp tubing (or begin flush) before the tubing drains completely .26. If administering more than one medication, flush with 15 ml (or prescribed amount) room temperature water between medications. 27. When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml of warm room temperature tap water (or prescribed amount) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 3 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week were used for 7 (Saturday 6/4/22, Sunday 6/5/22, Saturday 6/11/22, Saturday 7/9/22, Sunday 7/10/22, Saturday 8/27/22, Sunday 8/28/22) out of 26 days reviewed for RN coverage. The facility failed to maintain RN coverage for 8 hours a day/7days a week on Saturday 6/4/22, Sunday 6/5/22, Saturday 6/11/22, Saturday 7/9/22, Sunday 7/10/22, Saturday 8/27/22, Sunday 8/28/22. This failure could place residents at risk of adverse events and not having staff to attend to events. The findings were: Record review of the staffing schedule from 6/1/22-8/31/22 revealed 7 of 26 days there was not eight-hour continuous RN coverage on the weekends (Saturday/Sunday) for the following dates: Saturday 6/4/22 Sunday 6/5/22 Saturday 6/11/22 Saturday 7/9/22 Sunday 7/10/22 Saturday 8/27/22 Sunday 8/28/22 Interviewed the Administrator on 9/15/22 11:40 AM revealed she is aware the facility does not have full time coverage for an RN on the weekends. She stated the DON will come in on the weekends but not for 8 hours on Saturday and Sunday. She sated the CSD also will come in if there is a need. The Administrator stated they currently have and advertisement with online hiring agencies for RN's. The Administrator stated the facility will schedule RN's, and if a call in happens they will contact prn staff, and pool nurses to see if they can come in to cover shifts. Interviewed the CSD on 9/15/22 11:40 am, he stated he does not come in regularly to the facility to cover RN shifts on the weekends. He stated he will come to the facility if he is asked to come in as a consultant for an issue driven concern. He stated he is aware of the facility having difficulty staffing on the weekends and he and the corporate office have recently authorized a new position for RN coverage and are actively recruiting more RN's. Interviewed the DON on 9/15/22 12:15 PM, he stated he is on call by telephone 24 hours a day 7 days a week, he will come in on Saturday and/or Sunday for 3-5 hours a day when needed to complete paper-work tasks. He stated they have recently hired a new RN for the weekend shift, has advertisement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 4 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0727 with online hiring agencies and are actively recruiting more RN's. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 5 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate dispensing and administration of all drugs or biologicals) to meet the needs of each resident and ensure expired and discontinued drugs or biologicals were not available for use in 2 of 3 med aide carts (200 Hall and 400 Hall), 2 of 3 med aides (MA A and MA B) and 1 resident (Resident #6) reviewed for pharmacy services. MA A failed to remove a bottle of opened eye drops without a resident name and opened date prior to administering to Resident #6. MA A failed to ensure 5 bottles of opened and partially used eye drops that were without resident names and opened dates were removed from the 200 Hall med aide cart. MA B failed to ensure 2 bottles of opened and partially used eye drops without legible resident names and legible opened date was removed from the 400 Hall med aide cart. These failures could place residents at risk of infection, decline in health and hospitalization. Findings included: Resident #6 Record review of Resident #6's clinical record revealed a [AGE] year-old-male admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnoses included Covid-19, hemiplegia (paralysis to one side of the body), muscle weakness, cerebral infarction (stroke), aphasia (difficulty speaking and understanding) following cerebral infarction and Bell's palsy (weakness or paralysis of facial muscles). Record review of Resident #6's annual MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderately impaired cognition. He required supervision with 1 to 2 persons assistance for all ADLs. Record review of Resident #6's undated care plan revealed the following: Focus: Resident #6 has impaired visual function related to Cataracts and Hypermetropia (a vision problem in which nearby objects look blurred). Interventions did not include lubricant eye drops. Record review of Resident #6's Physician's Order Summary Report for active orders as of [DATE] revealed an order for Systane Solution 0.4-0.3 % (Polyethyl Glycol-Propyl Glycol) instill 1 drop in both eyes two times a day for Dry Eye Syndrome, start date [DATE]. During med pass observation on [DATE] at 6:45 AM revealed MA A administered Systane eye drops, 2 drops to both eyes for Resident #6. The opened bottle did not have a resident name or opened date. During an observation on [DATE] at 8:20 AM revealed the 200 Hall med aide cart contained 5 opened OTC bottles of eye drops in the top drawer. There was one bottle of Systane that had the number 210 handwritten on it. Another bottle of Systane and 3 bottles of Artificial Tears had black illegible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 6 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 markings. None of the bottles were in their original boxes. room [ROOM NUMBER] had two residents residing in the room. In an interview on [DATE] at 8:22 AM, MA A stated he writes the resident names and opened dates on the OTC eye drop bottles. He stated the bottle marked 210 is for Resident #6 in room [ROOM NUMBER] and who was the only resident in 200 Hall who received Systane eye drops. He stated if a resident changes rooms, he would toss the bottle. He stated he knew who the other bottles belonged to. When he was asked, how would other staff know who the bottles belong to, he had no reply and stated he will fix it now by notifying his nurse, get new bottles, keep the bottles in their original boxes, label the box with the resident names and opened dates. In an observation on [DATE] at 9:05 AM revealed the 400 Hall med aide cart contained 2 opened boxes of OTC Artificial Tears, with illegible writing. In an interview on [DATE] at 9:06 AM, MA B stated the names of the residents the boxes of artificial tears belonged to and that the resident names and open dates were written on the boxes. MA B stated possible risks would be blurred vision and blindness if eye drops were administered to the wrong resident. MA B stated she will dispose of the eye drop bottles and replace with new bottles, then identify them properly. In an interview on [DATE] at 12:00 PM, the DON stated eye drops should have the resident name on the label. When asked how he would know who the eye drops belong to if there are several opened bottles with no identifiers, the DON stated he would know by looking at the order. He stated the bottles would need at least 2 identifiers and the date when opened. He was asked what the risks would be, and he stated that it would be a problem with un-identified opened bottles, and it would be a med error. He stated they would toss the current eye drops and replace them and each bottle would have a separate name and date when opened. He stated all the eye drops will be tossed, new bottles will be kept in their boxes and labeled with resident name and room number. The bottles will be dated with date opened when the time comes to use it. In a telephone interview on [DATE] at 3:14 PM, the Pharmacist Consultant stated he visits the facility onsite every month and that he was at the facility last week for a routine visit. He stated he does not perform every task with each visit but typically covers drug destruction, spot check med pass reviews and med carts. He stated he checks the carts for cleanliness, organization, expired meds, and recent changes in orders. He stated this was done when he visited, and he had an intern who assisted. He stated eye drops are not shared and the residents initials or last name and date opened should be written on the bottle. He said typically if the writing is illegible, the product would be replaced. Record review of the facility's policy and procedure titled Instillation of Eye Drops, 2001 Med-Pass, Inc. (Revised [DATE]) reflected in part: Purpose - The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medial conditions, eye infections and dry eyes. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident Record review of facility's policy and procedures titled Administrating Oral Medications, 2001 Med-Pass, Inc. (Revised [DATE]) reflected in part: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation, 1. Verify that there is a physician's medication order for this procedure .Steps in the Procedure .6. Check the label on the medication and confirm the medication name and dose with the MAR .8. Check the medication dose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 7 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 Re-check to confirm the proper dose. Level of Harm - Minimal harm or potential for actual harm Record review of facility's policy and procedures titled Adverse Consequences and Medication Errors, 2001 Med-Pass, Inc. (Revised [DATE]) reflected in part: Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects . Policy Interpretation and Implementation .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medications errors include: a. Omission a drug is ordered but not administered; b. Unauthorized drug - a drug is administered without a physician's order; c. Wrong dose .d. Wrong rout of administration .e. Wrong dosage form .f. Wrong drug .g. Wrong time; .18. The QAPI Committee will conduct a root cause analysis of medication administration errors . Residents Affected - Some Record review of the facility's policy titled, Pharmacy Services Overview, 2001 Med-Pass, Inc. (Revised [DATE]) read in part: Policy Statement: The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency mediations and biologicals, and the services of a licensed Pharmacist. Policy Interpretation and Implementation: 1. The licensed Pharmacist shall collaborate with facility leadership and staff to coordinate pharmacy services within the facility, and to guide the development and implementation of pharmacy services procedures .3. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 8 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 each resident's drug regimen was free from unnecessary medications (without adequate indications for use) for 1 (Resident #92) of 19 residents reviewed for unnecessary medications: Residents Affected - Few Resident #92 received anticoagulant Coumadin (used to treat blood clots) without an appropriate indication for its use or proper diagnosis. This failure could place residents at risk of serious harm due to side effects, adverse reactions from the medication and receiving unnecessary medications. Findings included: Record review of Resident #92 's face sheet, dated 9/14/22, revealed an [AGE] year-old female was admitted to the facility on [DATE] and re-admission date 8/27/22. Her diagnoses included type 2 diabetes mellitus, atrial fibrillation (irregular heart rhythm), stage 3, chronic kidney disease and presence of cardiac (heart) pacemaker. Record review of Resident #92's physician's orders, dated September 2022, revealed an order to give Warfarin Sodium (Coumadin) 2 mg 1 tab in the evening, for dx other specified abnormalities of plasma proteins, start date 8/28/22. Record review of Resident #92's MAR, dated September 2022, revealed Resident #92 received routinely as ordered Warfarin Sodium (Coumadin) 2 mg 1 tab in the evening, for dx other specified abnormalities of plasma proteins, start date 8/28/22. During an interview on 9/14/22 at 2:30 p.m., the DON confirmed dx specified abnormalities of plasma proteins was inappropriate indication or dx for Resident #92's anticoagulant (Coumadin) use. The DON stated he would verify new admit orders the next day, to ensure if accurate, with appropriate indication for its use or proper dx, and corresponded with hospital discharge orders. During an interview on 9/14/22 at 2:35 p.m., the Unit Manager confirmed the overlooked inappropriate dx for anticoagulant use. She stated moving forward if unclear, she would ask questions or verify with the NP/MD. During an interview on 9/14/22 at 2:40 p.m., the ADON stated she would follow-up, and monitor new admit orders for anticoagulants to ensure proper dx or appropriate indication for its use. She stated she just took over less than 2 months ago as the ADON. She stated she would re-educate the admitting nurse, and ensure anticoagulant meds had an appropriate dx, and if unclear to ask questions or verify with NP/MD. The ADON stated dx of other specified abnormalities of plasma proteins was not the proper indication for Resident #92's anticoagulant Coumadin, but dx atrial fibrillation. During an interview on 9/14/22 at 3:30 p.m., the Administrator stated we would follow-up all issues on medications with QAPI. Record review of Resident #92 's care plan, date initiated (updated) 9/15/22revealed the resident was on anticoagulant therapy Warfarin (Coumadin) related to atrial fibrillation. Further noted to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 9 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete observe, document or report to MD as needed signs/symptoms of anticoagulant complications. Report abnormal lab results to MD. Record review of the facility's policy titled, Anticoagulation-Clinical protocol dated September 2012 reflected in part, The staff and physician will identify situation where anticoagulation may be indicated; for example, new onset deep vein thrombosis (DVT) . or atrial fibrillation. The staff and physician will identify and address potential complications in individuals receiving anticoagulation. The physician will order appropriate lab testing to monitor anticoagulant therapy . periodically checking platelets, PT/INR and stool for occult blood. Event ID: Facility ID: 676165 If continuation sheet Page 10 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who use antipsychotic drugs receive gradual dose reduction, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 15 residents (Residents #91) reviewed for unnecessary psychotropic meds. The facility administered an antipsychotic medication without adequate indications for its use and did not obtain a rationale for continuing the concurrent use of the psychotropic medication for Resident #91. This failure could place any resident on psychoactive medications and those with a diagnosis of dementia administered with antipsychotic meds, at risk for receiving unnecessary drugs and adverse reactions. Findings included: Record review of Resident #91's face sheet, dated 9/14/22, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, acute kidney failure, type 2 diabetes mellitus, syncope (dizziness), anemia and HTN. Record review of Resident #91's admission MDS assessment, dated 8/31/22 revealed Active Diagnoses did not have a check by the disorders Depression, Bipolar, Psychotic disorder or Schizophrenia. Mood interview reflected a total severity score=0. No hallucination or delusion were marked. His total BIMS score=10 indicating he had moderately impaired cognition. He required 1 staff supervision most ADLs. Further noted he understood other and was understood by others. Record review of Resident 91's Consent for Antipsychotic Medication Treatment, dated 8/28/22, revealed Seroquel was indicated to improve behavior and decrease in negative mood. Further noted Seroquel was indicated based on the following diagnostic criteria and assessment findings exhibited: Behavioral disturbance related to dementia. Resident has the following psychiatric condition, dx unspecified dementia. Record review of Resident #91's care plan, undated revealed the resident uses psychotropic meds due to fluctuations in his mood. Further noted he is taking anti-psychotic med Quetiapine (Seroquel) and he has ADL self-care performance deficit related to dx dementia. Record review of Resident #91's, Behavior Monitoring, dated September 2022, revealed to document the number of behaviors exhibited q shift. The monitoring reflected, Episodes: zero. No documentation of hallucinations or delusions. Record review of Resident #91's Physician's Order dated September 2022, revealed to give Quetiapine Fumarate (Seroquel) 25 mg 1 tab po at bedtime (qHS), for mood stabilization, start date 8/28/22.; and Donepezil HCl 23 mg 1 tab po qHS, for dx dementia, start date 8/28/22. Record review of Resident #91's MAR dated September 2022 revealed the resident received as ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 11 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Quetiapine Fumarate (Seroquel) 25 mg 1 tab po at bedtime (qHS), for mood stabilization, start date 8/28/22.; and Donepezil HCl 23 mg 1 tab po qHS, for dx. dementia, start date 8/28/22. During an interview on 9/14/22 at 2:30 p.m., the DON stated dx of mood stabilization was an inappropriate indication of use for Resident #91's antipsychotic med Seroquel. He stated he would verify new admit orders the next day, to ensure if accurate, with proper dx and corresponded with hospital discharge orders. During an interview on 9/14/22 at 2:40 p.m., the ADON stated she would follow-up and monitor antipsychotic meds and ensure the proper dx or appropriate indication for its use. She stated she would re-educate the admitting nurse if unclear regarding antipsychotic med or if with or without adequate indications for its use, to ask questions or verify with NP. She stated she just took over less than 2 months ago as the ADON. During an interview on 9/14/22 at 3:00 p.m., Unit manager A stated she would follow-up, ensure the residents antipsychotic med consents had appropriate dx and if unclear she would verify with the NP/MD. During an interview on 9/15/22 at 9:40 a.m. CNA E stated Resident #91 was no harm to himself or others, pleasantly confused and redirectable. She stated she had not seen him with any aggression but was forgetful. During an interview on 9/15/22 at 11:00 a.m. LVN C stated Resident #91 was redirectable but forgetful and pleasantly confused. She stated she had not seen him with any verbal or physical aggression. In an interview on 9/14/22 at 3:30 p.m., the Administrator stated they would follow-up all issues on medications with QAPI. Record review of the facility's policy titled, Antipsychotic Medication Use dated December 2016 reflected in part, antipsychotic meds may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social, and environmental causes of behavioral sx have been identified and addressed. Dx of specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of resident. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record . Schizophrenia; Schizoaffective disorder; Schizophreniform disorder; bipolar disorder, treatment refractory major depression; Psychosis in the absence of dementia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 12 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0759 Ensure medication error rates are not 5 percent or greater. 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 it was free of medication error rate of five percent or greater. A total of four errors out of 37 opportunities resulting in a 10.8 % error rate. One of four staff observed (MA A), made errors during the medication pass for 2 of 6 residents (Resident #6 and #65) reviewed for medication errors, in that: Residents Affected - Some MA A failed to administer the ordered dose of Tylenol and Systane eye drops to Resident #6. MA A failed to administer Tylenol at the ordered time and failed to administer the ordered dose of Tums to Resident #65. These failures could affect all residents who take medications and place them at risk of their medications not being administered per physician orders, at risk of inadequate therapeutic outcomes and decline in health. Findings included: Resident #6 Record review of Resident #6's clinical record revealed a [AGE] year-old-male admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnoses included Covid-19, hemiplegia (paralysis to one side of the body), muscle weakness, cerebral infarction (stroke), aphasia (difficulty speaking and understanding) following cerebral infarction and Bell's palsy (weakness or paralysis of facial muscles). Record review of Resident #6's annual MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderately impaired cognition. He required supervision with 1 to 2 persons assistance for all ADLs. Record review of Resident #6's undated care plan revealed the following: Focus: Resident has lymphedema (swelling due to blockage in the lymphatic system) to the right lower extremity, date initiated 08/13/2019. Interventions included: Administer pain medications as ordered. Focus: Resident #6 is at risk of acute pain. Interventions included: Observe/document for side effects of pain medication. Focus: Resident #6 has impaired visual function related to Cataracts and Hypermetropia (a vision problem in which nearby objects look blurred). Interventions did not include lubricant eye drops. Record review of Resident #6's Physician's Order Summary Report for active orders as of 09/14/2022 revealed an order for Tylenol 8-hour extended release 650 mg tablet and to give one tablet by mouth every 8 hours as needed for pain, start date 07/03/2021. There was an order for Systane Solution 0.4-0.3 % (Polyethyl Glycol-Propyl Glycol), instill 1 drop in both eyes two times a day for Dry Eye Syndrome, start date 05/21/2021. During med pass observation on 09/14/2022 at 6:45 AM revealed MA A prepared, dispensed, and administered 9 medications to Resident #6 of which 2 of the medication dosages administered were incorrect. MA A administered Acetaminophen 500 mg 2 tablets by mouth and Systane eye drops, 2 drops to both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 13 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0759 eyes. Level of Harm - Minimal harm or potential for actual harm In an interview and observation on 09/14/2022 at 1:40 PM, MA A stated there was a bottle labeled Non-Aspiring Extra-Strength: Acetaminophen 500mg tablets and a bottle labeled Acetaminophen 325 mg tablets in the 200 Hall medication aide cart. MA A stated he gave 2 tablets of Acetaminophen 325 mg and not 2 tablets of Acetaminophen 500 mg to Resident #6. MA A stated he gave one drop and not two drops of Systane eye drops to each eye for Resident #6. Residents Affected - Some In an interview on 09/14/2022 at 1:55 PM, the DON stated if they give more than the ordered dose of Tylenol they can't do that, they need to get an order for the higher dose. The DON stated if that happened the med aide would tell him, and it would be a medication error. The DON stated if the resident gets more Systane eye drops than ordered, the medication aide would not be following physician orders. The DON stated that would be a medication error and the medication aide would notify him. The DON stated, We tell medication aides and nurses to always go by what the doctor ordered. The DON stated the risk would be liver damage for a resident who received a higher dose of Tylenol than what was ordered by the physician. In an interview and observation on 09/14/2022 at 3:00 PM revealed Resident #6 was sitting in an electric wheelchair in the dining room. He was asked what the reason was for receiving Tylenol. Resident #6 pointed to the right side of his body, his right arm and the entire right leg. He demonstrated how limp his arm was, and he grimaced. When asked if the Tylenol was for pain, he nodded his head and said yes. When asked how he felt about receiving more Tylenol than what the physician prescribed, he said I don't know. When asked what the reason was for receiving eye drops, he squinted both eyes and motioned with his left hand. When asked if it was so he could see clearer, he nodded his head and said yes. When asked how he felt about receiving more eye drops than what the physician prescribed, he said I don't know. Resident #65 Record review of #65's clinical record revealed a [AGE] year-old-female admitted to the facility on [DATE] and originally admitted on [DATE]. Her diagnoses included Covid-19, major depressive disorder, type 2 diabetes, hypertension (elevated blood pressure), chronic pulmonary edema (condition caused by excess fluid in the lungs), obstructive uropathy (blockage of the flow of urine), acute respiratory failure, ulcerative colitis (inflammation of the colon), GERD, dementia and anoxic (deprived of oxygen) brain damage. Record review of #65's quarterly MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognitive response. She required supervision to limited one person assistance for all ADLs. Record review of #65's undated care plan revealed the following: Focus: Resident #65 had chronic pain related to Arthritis, date initiated on 04/17/2020. Goal: will display a decrease in behavior or inadequate pain control. Target date 09/22/2022. Interventions included: Administer analgesics as per orders and evaluate the effectiveness of pain interventions. Record review of #65's Physician's Order Summary Report for active orders as of 09/14/2022 revealed an order for Tums E-X 750 mg give, orally two times a day for GERD. Start date was 08/12/2021. Further review of the physician's order revealed an order for Tylenol tablet 325 mg (Acetaminophen), give 2 tablets by mouth every 6 hours as needed for pain, date started 08/15/2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 14 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of #65's MAR for September 2022 revealed the physician order for Tylenol 325 mg, two tablets every 6 hours was scheduled for 3:00 AM, 9:00 AM, 3:00 PM, and 9:00 PM. Record review of Resident #65's Medication Audit Report for August and September 2022 revealed the physician's order for Tylenol 325 mg, 2 tablets every 6 hours for pain was scheduled to be given 3:00 AM, 9:00 AM, 3:00 PM, 9:00 PM was given outside of the time parameters. The 3:00 AM dose was administered on 09/09/22 at 4:57 AM. The 9:00 AM dose was administered on 08/09/22 at 10:38 AM, 08/17/22 at 10:10 AM, 09/10/22 at 10:22 AM, 09/12/22 at 11:23 AM, 09/13/22 at 11:01 AM. The 3:00 PM dose was administered on 08/19/22 at 1:31 PM, 08/22/22 at 1:58 PM, 08/23/22 at 1:03 PM, 09/11/22 at 4:03 PM. The 9:00 PM dose was administered on 08/15/22 at 10:55 PM, 08/16/22 at 10:55 PM, 08/18/22 at 11:14 PM, Record review of Resident #65's August and September 2022 MAR revealed there were no follow up codes for the Tylenol given outside of the scheduled time parameters. During med pass observation on 09/14/2022 at 10:50 AM revealed MA A stated he was going to start by passing meds for the residents in room [ROOM NUMBER] and would work his way down the hall to room [ROOM NUMBER]. Further observation revealed there were 22 residents ahead of Resident #65. MA A agreed to start with Resident #65 who was in room [ROOM NUMBER]. At 11:00 AM, MA A prepared, dispensed, and administered 9 medications to Resident #65 of which one medication was administered outside of the prescribed administration time and one medication dosage was incorrect. The first medication was Tylenol 325 mg, two tablets scheduled to be given every 6 hours and the dose was due at 9:00 AM. The second medication administered was Tums 500 mg, one tablet. In an interview on 09/14/2022 at 11:05 AM, MA A stated when the medication order in the computer turns pink, it means that it's due and had been instructed by upper management to go ahead and give meds. When asked why the 9:00 AM dose of Tylenol was not given at the ordered time, MA A stated they can give morning meds between 6:00 AM - 12:00 PM. MA A stated normally he would be done with 200 Hall and would not be late with any meds in 300 Hall. MA A stated he will notify the nurse that the medications for Resident #65 were administered late. He notified LVN C that he was delayed because he was doing med pass with the Surveyor. LVN C said, Well, you need to have better time management. In an interview on 9/14/22 at 11:00 AM the MA Supervisor stated she would consider a medication to be late or an error if the ordered administration time was 6:00 AM and the med was given at 10:30 AM. In an interview on 09/14/2022 at 11:45 AM, the DON stated when the meds show up pink in the computer both the MA and nurse for that hall will see it. The DON stated pink tells the med aid or nurse to give that med now. He said it was not a med error when medication order is pink or red. In an interview on 09/14/2022 at 3:14PM, Resident #65 was told she received the 9:00 AM Tylenol at 11:00 AM. She said if Tylenol is not given to her every 6 hours as ordered she experiences increased pain. In an interview and observation on 09/15/22 at 8:20 AM, MA A stated he had a bottle of Tums 500 mg in the medication cart and gave 500 mg to Resident #65 when the order was for Tums 750mg. MA A stated he will notify the DON about the discrepancy in doses. In an interview on 09/14/2022 at 8:50 AM, the DON stated he did not think Tums came in 750 mg. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 15 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said he will change the order. He said since starting work at the facility in March 2022, he had been reconciling meds and had not gotten to the orders for Resident #65 yet. The DON later stated he found a bottle of Tums 750 mg and would label both bottles with the different doses since they looked similar. In an interview on 09/15/2022 at 12:20 PM, the Regional Nurse stated the liberalized medication administration times was designed to individualize the schedule for the residents. He stated some residents want to take their morning medications when they get up in the morning and the time would be different for everyone. The Regional Nurse stated the liberalized system allows for this. When asked about the pain med scheduled to be given every 6 hours and the 9:00 AM dose was given 2 hours later, he stated it would be outside of the parameters (one hour before and one hour after ordered time), and was a med error. He stated, We cannot liberalize the medications scheduled for every 6 hours. The Regional Nurse stated the DON and his clinical team would be responsible to review the schedule. He stated he would go to the DON and make sure the physician's order and administration times match. The Regional Nurse stated it may need to be adjusted to the actual times the resident received the pain meds. He said he knows the nursing staff had been monitoring Resident #65's pain levels. In an interview on 09/14/2022 at 1:00 PM, the DON said the system does not allow to change the times outside of the 3:00 AM-9:00 AM-3:00 PM-9:00 PM schedule. He stated the nurses don't have as many medications to give so he changed Resident #65's Tylenol order to be given by the nurse and not the med aide. He stated he wrote the med error for the Tylenol and Tums in Resident #65's chart and re-educated the medication aide. Record review of facility's policy and procedures titled Administrating Oral Medications, 2001 Med-Pass, Inc. (Revised October 2010) reflected in part: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation, 1. Verify that there is a physician's medication order for this procedure .Steps in the Procedure .6. Check the label on the medication and confirm the medication name and dose with the MAR .8. Check the medication dose. Re-check to confirm the proper dose. Record review of facility's policy and procedures titled Physician Medication Orders, 2001 Med-Pass, Inc. (Revised April 2010) reflected in part: Policy Statement: Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state .Policy Interpretation and Implementation .6. Orders for medications must include: .c. Dosage and frequency of administration Record review of facility's policy and procedures titled Adverse Consequences and Medication Errors, 2001 Med-Pass, Inc. (Revised April 2014) reflected in part: Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects . Policy Interpretation and Implementation .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medications errors include: . c. Wrong dose .e. Wrong dosage form The QAPI Committee will conduct a root cause analysis of medication administration errors . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 16 of 17 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 676165 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Tomball 250 School Street Tomball, TX 77375 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. Residents Affected - Many -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 09-13-22 at 8:45 a.m. revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster that was ¾ full of garbage and the door was open. Interview on 09-13-22 at 8:45 a.m. with the District Food Service Manager, she stated the dumpster lids must always be closed every time after facility staff disposed trash in the dumpster to keep vermin, pests and insects out of the dumpster and from entering the facility. Record review of the facility's policy and procedure on Environment dated September 2017 revealed: 6. All trash will be contained in covered, leak proof containers that prevent cross contamination. 7. All trash will be properly disposed of in external receptacles (dumpsters- doors will be kept closed) and the surrounding area will be free of debris. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 17 of 17