Health inspection·November 16, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm around the facility with his automated wheelchair so staff should have had time to change his sheets. She said she didn't know Resident #38 to deny laundry service. The DON said residents had the right to a clean and home like environment and after she was notified the facility did a sweep to ensure resident beds are clean. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 2 of 21 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 11/16/2023 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a comprehensive assessment of a resident within 14 calendar days after admission for 1 of 21 residents (Resident #207) reviewed for comprehensive assessments, in that: Resident #207 had no admission comprehensive assessment completed within 14 calendar days of admission. This failure may place residents at risk of not having all medical needs assessed and met. Findings included: Record review of Resident #207's face sheet , dated 11/16/2023, revealed a [AGE] year-old female was admitted into the facility on [DATE] and had diagnoses which included cerebral infarction, anoxic brain damage , acute respiratory failure, tracheostomy status and gastrostomy status. Record review of Resident #207's EHR revealed the resident had not yet had their MDS admission assessment completed, and the assessment reference date showed to be 2 days overdue. In an interview with MDS Nurse B on 11/16/2023 at 3:03 PM, she stated Resident #207's admission MDS was supposed to be locked, signed and submitted within 14 days of admission. She said she acknowledged the ARD on Resident #207's MDS was 11/14/23 and the admission MDS was two days overdue. She stated she was working on it at the moment, and that she was behind on her workload of completing the MDS assessments. She stated the purpose of deadlines was to ensure resident care is captured within the timeframe for CMS and for state regulatory purposes. She stated the resident could have missing information but would not say it impacted their care because their care plan was usually done. She stated the care plan is referred to for bedside care rather than the MDS. In an interview with the DON on 11/16/23 at 3:33 PM, the DON stated the MDS nurses refer to RAI manual. She stated she had never done MDS assessment, so she does not know the details. She stated they have a corporate level MDS nurse to refer to and that was probably auditing their work. She stated the MDS was used more for billing purposes and can relate to resident care, but the care plan usually came first. Record review of the RAI Manual, dated October 2019, reflected, .When admitting a resident from another nursing home, regardless of whether or not it is a transfer within the same chain, a new admission assessment must be done within 14 days . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 3 of 21 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 11/16/2023 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 0641 Ensure each resident receives an accurate assessment. 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 accurately assess each resident's status for 2 of 4 residents (Resident #52 and Resident #78) reviewed for assessment accuracy in that: Residents Affected - Some - The facility failed to accurately assess and document Resident #78's use of hearing aids. - The facility failed to ensure Resident #52's MDS reflected the correct pain medication regimen. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Resident #52 Review of Resident #52's Face Sheet dared 11/14/23 revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with Diabetes type 2 as the primary diagnosis and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) as the secondary diagnosis. Review of Resident #52 physician's medication order dated 6/14/2023 revealed, Tramadol to be given every 6 hours for pain. Review of the MAR for Resident #52's Tramadol administration dated from 9/10/2023 through 11/7/2023 revealed the resident was receiving Tramadol medication on a regular schedule of every 6 hours. Review of Resident #52's MDS dated [DATE], revealed Section J0100, regarding scheduled pain medication regimen required an answer to the question: Received scheduled pain medication regimen?. The answer was marked no. Interview with MDS Nurse A on 11/16/23 at 11:30am regarding section J0100 of the MDS for Resident #52. When asked why the MDS was not updated to reflect the medication regimen change to regularly scheduled medication every 6 hours, she stated that it was missed. The MDS nurse thought the order change came after MDS completion date and did not update the MDS record. Resident #78 Record review of Resident #78's Face Sheet dated 11/16/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), anxiety, muscle wasting, and depression. Record review of Resident #78's admission Report dated 05/09/23 revealed, Resident #78 admitted with a left ear hearing aid. Record review of Resident #78's MDS dated [DATE] revealed, ability to hear: adequate with no difficulty in normal conversation, social interaction, or listening to the tv. The MDS reflected Resident #78 had no hearing aid or other hearing appliance used and she understood verbal content. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 4 of 21 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 11/16/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation an interview on 11/14/23 at 10:20 AM revealed, Resident #78 lying in bed well dressed, well-groomed in no immediate distress with a pair of hearing aids on her bedside table. When asked questions, Resident #78 said she did not have her hearing aids in so she could not understand the surveyor. The surveyor asked the resident questions in writing and Resident #78 responded verbally. Resident #78 said she had hearing aids since she entered the facility but she didn't know how to put them in so her nursing staff helped her put them in daily. She said she did not have any issues with staff helping her with inserting her hearing aids and she would like someone to help her put them in. The surveyor notified MA A that Resident #78 would like help with her hearing aids. An observation and interview on 11/16/23 at 10:06 AM with the ADON revealed, the surveyor and ADON observing Resident #78 to confirm the presence of hearing aids. After exiting the resident's room CNA A confirmed Resident #78 used hearing aids and she helped her place them in and removed them daily. The ADON said she was unaware Resident #78 used hearing aids. In an interview on 11/16/23 at 10:10 AM, the DON said she was unaware that Resident #78 used hearing aids and she was unaware the resident admitted with hearing aids. She said upon assessment on admission nursing staff should identify the need for hearing aids and the resident's family could also notify the facility of the resident's use of hearing aids. She said Resident #78's use of hearing aids should have been documented in the MDS and failure to identify for a resident's use of hearing aids could result in issues with communication and the resident not having their needs met. In an interview on 11/16/23 at 02:20 PM, the DON said the facility did not have a policy for completing the MDS. She said the MDS nurses used the CMS provided RAI to complete the residents MDS. In an interview on 11/16/23 at 02:45 PM, MDS Nurse A said she Resident MDSs are completed by physically observing/interviewing the resident, reading the admissions records, talking to nursing/rehab staff and family. She said the areas documented in the MDS also trigger into the care plan. She said a resident's MDS should address the needs to take care of the resident, diagnoses and if a resident had hearing aids. She said she had seen Resident #78 but she never noticed the resident had hearing aids and was never informed by staff that the resident used hearing aids. She said failure to identify, document in the MDS a resident's use of hearing aids could place residents at risk for the inability to communicate adequately. In an interview on 11/16/23 at 03:10 PM, MDS Nurse B said she completed Resident #78's admission MDS. She said a residents MDS is completed by reviewing the resident's clinicals, and when the resident arrives the resident is interviewed and the pertinent information is collected. MDS Nurse B said the MDS is an interdisciplinary process and if a resident used hearing aids, hearing impairment should be documented in the MDS. She said she did not know how Resident #78's hearing aids were missed, but based on the admission report documenting the use of and the observed hearing aids on Resident #78 it should have been documented in the MDS. MDS Nurse B said failure to identify the use of hearing aids could result in a breakdown in communication between the resident and staff; she said staff could think the resident had behaviors and that the resident was ignoring them when she was just unable to hear. Record review of CMS's RAI Version 3.0 Manual revised 10/2023 revealed, B0200 (Hearing) Item Rationale Health-related Quality of Life- Problems with hearing can contribute to sensory (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 5 of 21 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 11/16/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some deprivation, social isolation, and mood and behavior disorders; Unaddressed communication problems related to hearing impairment can be mistaken for confusion or cognitive impairment. Planning for CareAddress reversible causes of hearing difficulty (such as cerumen impaction) ;Evaluate potential benefit from hearing assistance devices; Offer assistance to residents with hearing difficulties to avoid social isolation. Consider other communication strategies for persons with hearing loss that is not reversible or is not completely corrected with hearing devices; Adjust environment by reducing background noise by lowering the sound volume on televisions or radios. Steps for Assessment 1. Ensure that the resident is using their normal hearing appliance if they have one. Hearing devices may not be as conventional as a hearing aid. Some residents by choice may use hearing amplifiers or a microphone and headphones as an alternative to hearing aids. Ensure the hearing appliance is operational. 2. Interview the resident and ask about hearing function in different situations (e.g. hearing staff members, talking to visitors, using the telephone, watching TV, attending activities). 3. Observe the resident during your verbal interactions and when they interact with others throughout the day. 4. Think through how you can best communicate with the resident. For example, you may need to speak more clearly, use a louder tone, speak more slowly or use gestures. The resident may need to see your face to understand what you are saying, or you may need to take the resident to a quieter area for them to hear you. All of these are cues that there is a hearing problem. 5. Review the medical record. 6. Consult the resident's family, caregivers, direct care staff, activities personnel, and speech or hearing specialists. B0300 Hearing Aid Item Rationale Health-related Quality of Life : Many residents who own hearing aids do not have the hearing aids with them or have nonfunctioning hearing aids upon arrival. Planning for Care: Knowing if a hearing aid was used when determining hearing ability allows better identification of evaluation and management needs; For residents with hearing aids, use and maintenance should be included in care planning. Steps for Assessment 1. Prior to beginning the hearing assessment, ask the resident if they own a hearing aid or other hearing appliance and, if so, whether it is at the nursing home. 2. If the resident cannot respond, write the question down and allow the resident to read it. 3. If the resident is still unable, check with family and care staff about hearing aid or other hearing appliances. 4. Check the medical record for evidence that the resident had a hearing appliance in place when hearing ability was recorded. 5. Ask staff and significant others whether the resident was using a hearing appliance when they observed hearing ability (above). Coding Instructions: Code 1, yes: if the resident did use a hearing aid (or other hearing appliance) for the hearing assessment coded in B0200, Hearing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 6 of 21 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 11/16/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet resident's medical, nursing and mental and psychosocial needs which were identified in the comprehensive assessment for 1 of 5 residents(Resident #78) reviewed for care plans. -The facility failed complete a comprehensive care plan that addressed Resident #78's use of hearing aids. This failure could place residents at risk of not having their needs met, decreased quality of life or injury. Findings included Record review of Resident #78's Face Sheet dated 11/16/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), anxiety, muscle wasting, and depression. Record review of Resident #78's admission Report dated 05/09/23 revealed, Resident #78 admitted with a left ear hearing aid. Record review of Resident #78's MDS dated [DATE] revealed, ability to hear: adequate with no difficulty in normal conversation, social interaction, or listening to the tv. Resident #78 had no hearing aid or other hearing appliance used and she understood verbal content. Record review of Resident #78's undated Care Plan revealed, focus areas of: seizure disorder, difficulty breathing, anxiety, hypotension. There was no documentation of Resident #78's hearing impairment or the use of hearing aids. Record review of Resident #78's Care Plan Conference Summary dated 08/08/23 revealed, no documentation of Resident #78's hearing impairment or use of hearing aids. Record review of Resident #78's admission Screener dated 05/09/23 revealed, no documented use of hearing aids or a diagnosis of hearing impairment. Record review of Resident #78's Care Plan Conference Summary dated 08/08/23 revealed, no documentation of Resident #78's hearing impairment or use of hearing aids. An observation an interview on 11/14/23 at 10:20 AM revealed, Resident #78 lying in bed well dressed, well-groomed in no immediate distress with a pair of hearing aids on her bedside table. When asked questions Resident #78 said she did not have her hearing aids on so she could not understand the surveyor. The surveyor asked the resident questions in writing and Resident #78 responded verbally. Resident #78 said she had hearing aids since she entered the facility but she didn't know how to put them on so her nursing staff helped her put them in daily. She said she did not have any issues with staff helping her with inserting her hearing aids and she would like someone to help her put them on. The surveyor notified MA A that Resident #78 would like help with her hearing aids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 7 of 21 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 11/16/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An observation and interview on 11/16/23 at 10:06 AM with the ADON revealed, the surveyor and ADON observed Resident #78 to confirm the presence of hearing aids. After exiting the resident's room CNA A confirmed Resident #78 used hearing aids and she helped her place them in and remove them daily. The ADON said she was unaware used hearing aids. In an interview on 11/16/23 at 10:10 AM, the DON said she was unaware that Resident #78 used hearing aids and she was unaware the resident admitted with hearing aids. She said upon assessment on admission nursing staff should identify the need for hearing aids and the resident's family could also notify the facility of the residents use of hearing aids. She said Resident #78's use of hearing aids should have been documented in care plan and failure to identify/plan for a resident's use of hearing aids could result in issues with communication and the resident not having their needs met. In an interview on 11/16/23 at 02:20 PM, the DON said a resident's care plan should be complete and show a full picture of the resident, as well as their diagnosis. She said Resident #78's care plan should have included her use of hearing aids and failure to have an accurate care plan could result in the resident not having their needs met. In an interview on 11/16/23 at 02:45 PM, MDS Nurse A said she Resident MDSs are completed by physically observing/interviewing the resident, reading the admissions records, talking to nursing/rehab staff and family and the care plan is also triggered by the identified areas in the care plan. She said a resident's care plan should address the needs to take care of the resident, diagnoses and if a resident had hearing aids their care plan should reflect that. She said she had seen Resident #78 but she never noticed the resident had hearing aids and was never informed by staff that the resident used hearing aids. She said failure to identify and care plan a resident's use of hearing aids could place residents at risk for the inability to communicate adequately. In an interview on 11/16/23 at 03:10 PM, MDS Nurse B said she completed Resident #78's admission MDS. She said a resident's MDS is completed by reviewing the resident's clinicals, when the resident arrives the resident is interviewed, and the pertinent information is collected. MDS Nurse B said the MDS and care plan are an interdisciplinary process and if a resident used hearing aids the resident should be care planned for hearing aids. She said she did not know how Resident #78's hearing aids were missed, but based on the admission report documenting the use and the observed hearing aids on Resident #78 it should have been documented in care plan. MDS Nurse B said failure to care plan for hearing aids/identify the use of hearing aids could result in a breakdown in communication between the resident and staff; she said staff could think the resident had behaviors and that the resident was ignoring them when she was just unable to hear. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered revised 12/2016 revealed, 1- the IDT team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 8: b-The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. G-incorporate identified problem areas; incorporate risk factors associated with identified problems. 13- Assessments of residents are ongoing and care plans are revised as information about the residents and resident's conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 8 of 21 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 11/16/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 8 residents (Resident #74) reviewed for quality of care. Residents Affected - Some - The facility failed to properly assess Resident #74 when she returned to the facility with a dressing of approximately 5 X 5 inches located on her right chest under the collarbone from 11/07/23 to 11/14/23. This failure could place residents at risk of late identification of wounds and or worsening of current wounds as well as infection. Findings Included: Record review of Resident #74's Face Sheet dated 11/14/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: COPD, bipolar disorder, anxiety disorder, chronic pain syndrome, hypertension abd rheumatoid arthritis. Record review of Resident #74's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, supervision with most ADLs, occasionally incontinent of bladder and frequently incontinent of bowel. Record review of Resident #74's undated Care Plan revealed, focus- impairment to skin integrity related to surgical incision to the left neck, focus- keep skin clean and dry, observe skin injury for abnormality and administer treatment as ordered. Record review of Resident #74's Progress Notes dated 11/07/23 at 08:45 PM and signed by LVN D revealed, Resident #74 returned to the facility with a surgical incision noted to right side of neck, clean dry, intact. No signs of infection, no redness, no bleeding, A suture was used to close the muscle on her neck and Dermabond (medical skin adhesive) was applied. There was no documentation of Resident #74's dressing or what lay underneath the dressing. Record review of Resident #74's Weekly Skin Review dated 11/10/23 at 04:39 PM revealed, Resident #74 had no bruises, no redness and her skin was intact. There was no documentation about the dressing located on her right chest or her surgical incision site on her neck. Record review of Resident #74's Oder Summary Report dated 11/16/23 revealed, no documented orders for care to the right upper chest. An observation and interview on 11/14/23 at 09:40 AM revealed, Resident #74 walking around in her room, well dressed, well groomed, in no immediate distress hanging up her clothes. Resident #74 had a visible surgical incision site going down the right side of her neck and an unlabeled gauze dressing approximately 5 X 5 under her right clavicle. The dressing appeared dingy and was slightly detached from the skin at the top. Resident #74 said the dressing was placed on her after she had a surgical procedure on 11/06/23. She said the facility staff had not performed care to the area since she returned on 11/06/23; had not assessed the area or talked to her about it. Resident #74 said she didn't know what the dressing was there for. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 9 of 21 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 11/16/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation on 11/14/23 at 03:30 PM revealed, Resident #74 sitting outside on the patio with the dressing removed from her right upper chest. She said the nurse had removed the dressing and there was nothing under the dressing. The surveyor observed the residents skin to be intact in the area the dressing had sat, In an interview on 11/14/23 at 10:05 AM, LVN A said she did not receive Resident #74 when she returned to the facility on [DATE]. She said if a resident returned with a dressing from an outside appointment the receiving nurse should assess the area, change the dressing with a date and orders to care for the area should be entered. She said she had worked with Resident #74 since she returned on 11/07/23 and had observed the dressing but did not know what the dressing was for. LVN A said to her knowledge Resident #74 did not have orders for care to the area, she had not assessed the area, provided care to the area and care to the area did not appear on her TAR. LVN A said failure to assess a dressed area following resident re-admission to the facility could result in late identification of wounds that if left untreated could result in an infection. She could not explain why she had not questioned why Resident #74 had a dressing or why she did not assess the area since she observed the dressing. In an interview on 11/14/23 at 10:26 AM, the DON said that if a resident returned to the facility with a dressing that was not there at transfer, nursing staff are expected to assess the area and apply a dated dressing if no discharge orders were given. The DON said depending on what the nurse identified, orders should be entered to care for the area and the treatment nurse should be notified. She said she and LVN A assessed the area under Resident #74's right chest dressing after LVN A was questioned about the dressing by the surveyor and there was nothing there. The DON said the dressing was most likely placed after the hospital removed a central line from Resident #74 following the procedure. She said that nursing staff should have assessed Resident #74 after she returned from the hospital with the dressing to find out what was under the dressing and Resident #74 should not have had the dressing for a week without care being provided. The DON said failure to assess a dressed area following a resident's return from the hospital could result in delayed identification of a wound placing residents at risk for infection. On 11/14/23 at 10:26 AM, the surveyor requested the facility policy on skin assessments and wound care from the DON. The policies were not provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 10 of 21 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 11/16/2023 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 - Many 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 observation, interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day 7 days a week from 10/2/2023 to 10/7/2023, 10/9/2023 to 10/13/2023, 10/15/2023 to 10/31/2023 and 11/1/2023 to 11/16/2023. The facility had no DON from 9/29/2023 to 10/10/2023. These failures placed the residents at risk for not having decisions made that would have required an RN to make in the management of the resident's healthcare needs and in managing and monitoring of the direct care staff. Findings: Record review of employee file revealed the previous DON termination date of 9/29/2023. Record review of employee file revealed current DON hire date of 10/10/2023. Record review of employee time stamps revealed no significant RN coverage for 10/2023 . Record review of employee files revealed no RN coverage from 11/1/2023 to 11/16/2023. In an interview on 11/15/2023 at 4:00pm with the DON, she said there were no health needs in the facility for RNs. She said they had no acuity for RNs. She said she had come into the facility on some weekends and worked to learn and update her position as a DON at the facility since starting her position. When asked what days she came in on weekends she did not give an answer. She said when she came in, she was not doing any patient care or acting as a charge nurse. She said she was not at the facility on 11/11/2023 or 11/12/2023. She said there was a difference in the educational levels of an RN and an LVN. She said LVNs were not able to assess and stage a wound and having an RN in the building could have helped with that. She said as a DON the importance of having a registered nurse at the facility was being able to assess a change in condition and having a resource for the LVNs. In an interview on 11/16/2023 at 7:45am with the DON, she said they did not use contracted staff for RN coverage. In an interview on 11/16/2023 at 7:45am with the Clinical Services Director, he said they had problems getting an RN for the past year. He said they are located next to a hospital, so it made hiring RNs more difficult. He said they did not use temporary agencies for filling the gaps in coverage for registered nurses. Record review of facilities policy titled, Staffing dated 2001 reflected in part . Our facility maintains adequate staffing on each shift to ensure that our residents needs and services are met. Licensed registered nursing and licensed nursing are available to provide and monitor the delivery of resident care services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 11 of 21 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 11/16/2023 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, record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 8 residents (Resident#58) and 1 out of 4 Med Carts (400 Hall Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure Resident #58's rapid-acting pre-prandial insulin (insulin that should be administered within 5-20 minutes before meals), NovoLog, was administered without regard to the facility scheduled or actual meal times. - The facility failed to ensure the 400 Hall nursing Cart did not contain expired liquid protein supplements. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and hospitalization. Findings Include: Resident #58 Record review of Resident #58's Face Sheet dated 11/16/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: depression, anxiety, and type 2 diabetes. Resident #58 room was on the 400 hall. Record review of Resident #58's Order Summary dated 11/16/23 revealed: - Night time snack at bedtime with effective date 07/11/22, there were no other orders scheduled snacks. - Novolog Insulin- Inject as per sliding scale subcutaneously before meals and at bedtime for DM: BS 201-250= give 8 units; 251-300= give 10 units; 301-350= give15 units; 351-400= give 18 units and call MD/NP with effective date 09/15/23. - Hypoglycemic protocol- follow hypoglycemia protocol is blood sugar is less than 70 mg/dl. Record review of Resident #58's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, a diagnosis of diabetes but the use of insulin or any hypoglycemic medications (blood sugar lowering) was not documented. Record review of Resident #58's Blood Sugars from 08/01/23 to 11/16/23 revealed no documented evidence of hypoglycemia (BS<70). Record review of the facility's Meal Service Times provided on 11/14/23 revealed, - Breakfast scheduled for 07:30 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 12 of 21 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 11/16/2023 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 - Lunch scheduled at 11:30 AM. Level of Harm - Minimal harm or potential for actual harm - Dinner scheduled at 05:30 PM. Residents Affected - Some Record review of Resident #58's Novolog Insulin Administration Records revealed, Resident #58's insulin was scheduled at intervals that were 1 hour before meals for breakfast (06:30 AM) and Dinner (04:30 PM) and the resident received insulin on the following dates: - 11/15/23 scheduled dose at 11:30 AM; 8 units were administered at 11:35 AM - 11/15/23 scheduled dose at 06:30 AM; 10 units was administered at 06:50 AM. - 11/14/23 scheduled dose at 04:30 PM; 8 units administered at 04:22 PM. - 11/13/23 scheduled dose at 04:30 PM; 8 units administered at 04:17 PM. - 11/12/23 scheduled dose at 04:30 PM; 10 units administered at 04:24 PM. - 11/12/23 scheduled dose at 06:30 AM; 8 units administered at 06:30 AM. - 11/11/23 scheduled dose at 04:30 PM; 10 units administered at 4:27 PM. - 11/10/23 scheduled dose at 04:30 PM; 10 units administered at 04:44 PM. - 11/09/23 scheduled dose at 04:30 PM; 10 units administered at 04:44 PM. - 11/10/23 scheduled dose at 04:30 PM; 10 units administered at 04:35 PM. In an interview on 11/15/23 at 07:20 AM, LVN B said she was the nurse for the 400 hall and she had administered insulin to all the residents on her hall between 06:30-7:00 AM. LVN B said breakfast was scheduled to arrive at 07:30 AM. An observation on 11/15/23 at 07:45 AM revealed, breakfast carts were not on the floor and no residents in the building had yet received breakfast. An observation on 11/15/23 at 08:00 AM revealed, breakfast had not been delivered to the 400 hall. An observation at 11/15/23 at 11:35 AM revealed, LVN B preparing for insulin administration to Resident #58; there were no dietary carts on the floor and there were no staff passing out trays. LVN B entered into Resident #58's room and tested her BS which resulted as 346, she then returned to her cart and prepared 15 units of Novolog for administration to Resident #58. LVN B entered into Resident #58's room and administered 15 units of NovoLog to the resident in her left lower abdomen. The surveyor observed different snack items on the resident's bedside table and nightstand. In an interview on 11/15/23 at 11:39 PM, Resident #58 said she has not had experienced any signs and symptoms of low blood sugar and the facility never offered her snacks between her insulin and meals. An observation at 11/15/23 at 12:20 PM revealed, Resident #58 receiving her lunch tray. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 13 of 21 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 11/16/2023 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 In an interview on 11/16/23 at 10:22 AM, the DON said that NovoLog is a fast-acting insulin that is administered within 30 minutes of meals. When asked if she was aware that nursing staff administered sliding scale rapid acting insulin at scheduled times and without regard of meals, the DON did not answer. The DON said Resident #58 had no history of hypoglycemia. She said sliding scale pre-prandial insulin should be administered in anticipation of an upcoming meal and if administered before without regard for meals it could place residents at risk of dropping blood sugars and hypoglycemia. The DON said the facility did not provide snacks specifically to residents receiving insulin between insulin administration and meals if meals were delivered late and administering insulin without regards to meals would result in non-ideal glucose control as well as hypoglycemia. 2. In an observation and interview on 11/15/23 at 08:45 AM, inventory of the 400 Hall Nursing Cart with LVN B revealed: - one open and expired Active Liquid Protein with open date 04/24/23 and manufacturer's instructions to discard 3 months (07/24/23) after opening. LVN B said nursing staff were expected to check their carts daily for expired medications/OTC supplements. She said she did not know the liquid protein expired 3 months after being opened and since the bottle was open in April of 2023 it was expired. LVN B said expired protein supplement must be discarded because use could lead to GI upset so it must be discarded in the trash. In an interview on 11/16/23 at 03:32 PM, the DON said nursing staff are expected to check their carts daily as used for expired and inappropriately labeled medications as used. She said expired liquid protein supplements could place residents at risk of inadequate supplementation or GI upset so the item should be discarded in the trash. Record review of the facility policy titled Storage of Medications revised 04/2007 revealed, 2- the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 4- the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be returned to the dispensing pharmacy or destroyed. Record review of the facility policy titled Administering Medication revised 12/2012 revealed, 9- the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Record review of the facility policy titled Insulin Administration revised 09/2014 revealed, 5- The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Characteristics and types of insulin- onset of action- how quickly the insulin reaches the bloodstream and begins to lower the blood glucose; peak effects- the time when the insulin is at its maximum effectiveness. Type: Rapid-acting; onset*- 10-15 minutes; peak- 0.5-3 hrs*; duration- 3-6 hrs. *varies with manufacturer- see package inserts. Record review of NovoLog Insulin Package Insert revised 02/2023 revealed, NovoLog is a rapid acting insulin used to improve blood sugar control in adults and pediatric patients with DM. Inject NOVOLOG® subcutaneously within 5-10 minutes before a meal into the abdominal area, thigh, buttocks or upper arm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 14 of 21 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 11/16/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure irregularities noted by the pharmacist were acted upon for 1 (Resident #26) of 5 residents reviewed for pharmacy review. The facility failed to ensure: - The pharmacist's Director of Nursing Report dated October 13,2023 reflected order for Aspirin capsule 81mg daily be updated for Resident #26. - The pharmacist's Director of Nursing Report dated October 13, 2023, recommended changing Lipitor from morning to bedtime for Resident #26. These failures could place residents at risk for having a change in condition and not having the desired therapeutic effect. Findings included: Record Review of Resident #26's Face Sheet revealed an [AGE] year-old male who was admitted on [DATE] with a diagnoses of syncope and collapse (Fainting), chronic kidney disease (Damaged kidneys), hyperlipidemia (High Cholesterol (Fats), trans cerebral Ischemic attack (Brief blockage of blood supply to brain), atherosclerotic heart disease of native coronary artery without angina pectoris (Buildup of fats and cholesterol without chest pain). Record Review of Resident #26's quarterly MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating the resident was severely cognitively impaired. Resident #26 required limited assistance with bed mobility, locomotion on unit, locomotion off unit, dressing, toilet use and personal hygiene. Section I revealed active diagnoses were coronary artery disease (Fats and cholesterol block heart arteries), peripheral vascular disease (Fats and Cholesterol Block lower vessels) diabetes mellitus (High blood sugar), cerebral vascular accident (Blockage of blood to the brain). Record review of Resident #26's Care Plan dated 11/15/2022 to present reflected in part .[Resident #26] has coronary artery disease r/t Atherosclerosis. Record review of the Director of Nursing Report dated 10/13/2023 reflected Order for Aspirin capsule 81mg daily. Suggest clarify aspirin 81mg EC or Chewable tablet based on house stock availability and swallow status. Change Lipitor admin from M to HS. Record review of Resident #26's Medication orders reflected in part .8/22/2023 Aspirin Oral Capsule 81mg Give 1 capsule by mouth one time a day for heart healthy . 8/22/2023 Atorvastatin Calcium 20mg Tablet Give 1 tablet by mouth 1 time daily. Record Review of Resident #26's Medication Administration Record revealed the resident's Lipitor (Atorvastatin) was administered in the morning hours of 11/1/2023 to 11/16/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 15 of 21 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 11/16/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #26's clinical record revealed no physician review of pharmacy recommendations. Record review of facility pharmacy book revealed no physician review of pharmacy recommendations. Record review of the pharmacy Director of Nursing Report dated October 13, 2023, revealed a check mark next to Order for Aspirin capsule 81mg daily. Suggest clarify as aspirin 81mg EC or chewable tablet based on house stock availability and swallow status. In an interview on 11/15/2023 at 15:00 with the ADON she said she had been working at the facility for almost 2 years. She said she had been taking the lead on pharmacy review since the last DON left. She said pharmacy came in every month and reviewed the charts. She said pharmacy emailed the recommendations to the facility and she printed them. She said if the changes were basic, she changed them and put a check next to them when completed. She said if there were a change in the medications, she ran it by the Nurse Practitioner and got an order for it. She said the medication recommendations from pharmacy were for a reason. She said the risk to a resident if pharmacy recommendations were not followed, residents could have had a change in condition and the medication would not have had the desired therapeutic effect. She said she did not know what time of day the body produced cholesterol. When the surveyor asked why the pharmacy recommendations for aspirin and Lipitor were not followed, she did not answer. In an interview on 11/15/2023 at 3:05pm with the DON she said she had been at the facility for a little over a month and she had been a nurse for twenty-three years. She said if pharmacy recommendations were not followed the resident would not have had the desired effect from the medication. She said the resident may also have had a change in condition. Record review of the facility's policy titled, Medication Regimen Reviews , dated 2001 reflected in part . The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately. The consultant pharmacist will document his/her findings and recommendations on the drug/medication regiment review report. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 16 of 21 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 11/16/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for 1 out of 4 medication carts ( 300 Hall Medication Aide Cart ) reviewed for medication storage. - The facility failed to ensure the 300 Hall Medication Aide Cart did not contain inappropriately labeled and in use protein supplements. These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: In an observation and interview on 11/15/23 at 12:15 PM, inventory of the medication 300 Hall Medication Aide Cart with MA B revealed: - one open and in use bottle of Active Liquid Protein with no open date and manufacturers instructions to discard 3 months after opening. MA B said nursing staff are expected to check their carts daily as used for loose pills, inappropriately labeled and expired medications/supplements. He said multidose containers should be labeled with their open date in order to track the expiration date. He said he was unaware that the liquid protein was only good for 3 months and since the bottle did not have an open date it could be expired and could not be used. He said use of expired liquid protein could place residents at risk of GI upset so the item must be discarded. In an interview on 11/16/23 at 03:32 PM, the DON said nursing staff are expected to check their carts daily as used for expired and inappropriately labeled medications. She said multidose containers like the liquid protein should be labeled with the date opened in order to track the expiration date. She said an unlabeled multidose bottle of liquid protein might actually be expired and the use of expired protein supplement could place residents at risk of inadequate supplementation or GI upset so the item should be discarded in the trash. Record review of the facility policy titled Storage of Medications revised 04/2007 revealed, 2- the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.4- the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals, all such drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 17 of 21 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 11/16/2023 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 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 2 of 8 residents (CR #1 and CR #2) whose records were reviewed for accuracy and completeness. - The facility failed to maintain complete and accessible records of medication administration times for CR #1 and CR #2. These failures could place residents at risk of having incomplete or inaccurate records. Findings included: CR #1 Record review of CR #1's Face Sheet dated 11/16/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: abscess of chest wall and hypertension. The resident discharged from the facility on 03/31/23. Record review of CR #1's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, limited assistance with most ADLs, received PRN pain medication, received an anticoagulant, received an antibiotic, received an opioid occasionally incontinent of bladder and always continent of bowel. Record review of CR #1's undated Care Plan revealed, focus- risk for acute pain related to fracture; intervention- administer analgesia as per orders. Focus- antibiotic therapy related to osteomyelitis (bacterial bone infection), intervention-administer mediation as ordered. Record review of CR #1's Order Summary dated 11/16/23 revealed the resident had orders for the following medications during his residency: - Acetaminophen 650 mg - give 1 tablet by mouth every 4 hours as needed for pain 1-3/temp >100 .5 degrees Fahrenheit and headache. - Apixaban 5 mg- give 1 tablet by mouth 2 times a day for Afib (irregular heart beat that puts residents at risk for blood clots). - Aspirin 81 mg- give 1 tablet by mouth one time a day to prevent blood clot - Atorvastatin 40 mg- give 1 tablet by mouth at bedtime for high cholesterol. - Carvedilol 12.5 mg- give 1 tablet by mouth 2 times a day for hypertension; hold for SBP <100 and HR< 60. - Cefepime (an antibiotic) IV Solution- use 1 gram intravenously every 8 hours for osteomyelitis until 05/05/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 18 of 21 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 11/16/2023 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 0842 - Clonidine 0.1 mg- give 1 tablet by mouth every 4 hours as needed for hypertension; give if SBP >160. Level of Harm - Potential for minimal harm - Ibuprofen 400 mg- give 1 tablet by mouth every 8 hours as needed for inflammation/pain. - Nicotine Patch 21 mg/24 HR- apply 1 patch to the skin one time a day for smoking cessation. Residents Affected - Some - Hydrocodone 5-325 mg- give 1 tablet by mouth every 4 hours as needed for pain. - Vancomycin (an antibiotic) IV solution- use 1.75 grams intravenously at bedtime for wound infection until 05/05/23 to be given via pump. - Vancomycin (an antibiotic) IV solution- use 1.5 grams intravenously every 12 hours for osteomyelitis until 05/05/23. Record review of CR #1's March 2023 MAR revealed no documented medication administration times. Record review of CR #1's EMR revealed, documented times for progress notes and assessments. There were no records of medication administration times. CR#2. Record review of CR #2's Face Sheet dated 11/16/23 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: Heart failure, type 2 diabetes, high cholesterol, hypertension and pressure ulcers. CR #1 discharged from the facility on 05-19-23. Record review of CR #2's Order Summary dated 11/16/23 revealed the resident had orders for the following medication during his residency: - Admelog insulin- inject as per sliding scale: if 121 - 150 = 2 units ; 151 -200 = 4 units ; 201 - 250 = 6 units ; 251 - 300 = 8 units ; 301 - 350 = 10 units; 351 - 399 = 12 units;400+ = 14 units notify NP , subcutaneously before meals and at bedtime for DM. - Vitamin C (ascorbic Acid) 500 mg - give 1 tablet by mouth daily for wound. - Aspirin 81 mg- give 1 tablet by mouth in the evening for heart health. - Benzonatate 100 mg- give 1 capsule by mouth every 8 hours as needed for cough. - Calcium Carbonate 500 mg- give 1 wafer by mouth three times a day for GERD (acid reflux). - Carvedilol 3.125 mg- give 1 tablet by mouth 2 times a day for hypertension; hold for SBP <120 or HR<60. - Cetirizine 5 mg- give 1 tablet by mouth one time a day for allergy. - Citalopram 10mg- give 1 tablet by mouth one time a day for depression. - Clopidogrel 75 mg- give 1 tablet by mouth in the evening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 19 of 21 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 11/16/2023 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 0842 - Docusate 100 mg- give 2 tablets by mouth one time a day for constipation. Level of Harm - Potential for minimal harm - Furosemide 40 mg- give 1 tablet by mouth one time a day for HF. Residents Affected - Some - Hydrocodone- Acetaminophen 5/325 mg- give 1 tablet by mouth every 4 hours as needed for moderate pain. - Hydrocodone- Acetaminophen 5/325 mg- give 1 tablet by mouth every 8 hours as needed for moderate pain. - Hydrocodone- Acetaminophen 5/325 mg- give 2 tablets by mouth every 6 hours as needed for pain from 04 to 10. - Insulin Glargine- inject 10 units under the skin in the morning for diabetes - Ipratropium Bromide 0.02% Inhalation Solution- 1 inhalation orally every 6 hours as needed for SOB. - Multivitamin w/ Minerals- 1 tablet by mouth one time a day for supplement. - Potassium Chloride 20 mEq- give 1 tablet by mouth one time a day. - Sacubitril-Valsartan 24-26 mg- give 1 tablet by mouth 2 times a day for CHF. - Simvastatin 20 mg- give 1 tablet by mouth in the evening for high cholesterol. - Tamsulosin 0.4 mg- give 1 capsule by mouth in the evening for urine retention. - Zinc 50 mg- give 1 tablet by mouth one time a day for supplement. Record review of CR #2's May 2023 MAR revealed, no documented medication administration times. Record review of CR #3's EMR revealed, times documented within the EMR for progress notes and assessments. There were no records of medication administration times. In an interview on 11/16/23 at 03:54 PM, the Regional [NAME] President of Operations said medication administration times are not available to surveyors after resident's discharged because they are not part of the clinical record assessable to SA surveyors. He said facility administration had access to medication administration times for discharged residents through the 'Medication Audit Report' located in the EMR system but the information would not be provided because it is part of their quality system and it is not provided to the state survey agency. When asked if there was any other way to identify medication administration times for discharged residents without the 'Medication Audit Report' the Regional [NAME] President of Operations said no. When asked why medication administration times were the exception to the clinical record when timestamps were available for assessments, progress notes, and other records located in the EMR, the Regional [NAME] President of Operations would not answer. When asked what the facility considered a complete clinical record, the Regional [NAME] President of Operations would not answer and deferred the question to the Administrator. In an interview on 11/16/23 at 04:04 PM, the Administrator said a resident's clinical record should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 20 of 21 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 11/16/2023 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 0842 Level of Harm - Potential for minimal harm Residents Affected - Some provide a full picture of a resident and include the resident's medications, orders and medication administration information. When asked why it was important to document medication administration times the Administrator said the importance of medication administration times was to access if medications were given on time. He said he did not know why the medication administration time was the exception to a resident's clinical record when times were documented for all other aspects of the medical record. The Administrator said it was determined by the company administration that the records would not be available to the surveyors. Record review of the facility policy titled Administering Medication revised 12/2012 revealed, 20- as required or indicated for a medication; the individual administering the medication will record in the resident's medical record: a- the date and time the medication was administered. Record review of the facility policy titled Electronic Medical Records revised 03/2014 revealed, electronic medical records may be used in lieu of paper records when approved by the Administrator. 7- Authorized Federal and State survey agents. etc., as outlined in current regulations, may be granted access to electronic medical records. Record review of Texas HHHSC Provider Letter titled PL 2018-26 Providing Access to Electronic Health Records revised 12/10/18 revealed, Providers must grant access to all electronic health records (EHRs) when requested by a surveyor. 2- During an entrance conference, a provider must explain to a survey team requesting access to EHRs how the provider is giving surveyors secure and unrestricted access to the EHRs. If a provider impedes the survey or investigation process by unnecessarily delaying or restricting access to EHRs, HHSC may take adverse certification or licensure action against a provider. Record review of the CMS 'Survey and Certification Letter 09-53' dated 08/14/09 revealed, Access to Records by Surveyors: During the entrance conference, surveyors will verify with the facility the process they will follow in order to have unrestricted access to the medical record. Impeding the survey process by unnecessarily delaying or restricting access to the medical records may lead to termination from Medicare participation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 21 of 21