Health inspection·November 24, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some evidence supporting the allegation of theft or diversion. The allegations appear to be malicious in nature, potentially made by an individual known to [MA A] from a previous place of employment. Conclusion: Based on the internal audit, staff interviews, and law enforcement input, there is no substantiated evidence of medication diversion or misconduct by [MA A]. No further investigation is warranted at this time. Corrective/Preventative Measures: continued routine medication carts audits will be performed. Staff reminded to immediately report any concerns of potential diversion. Documentation of this investigation will be retained in the Administrator's reference. Record review of the Police Department Call Record Dated [DATE] revealed, on [DATE] at 03:26 PM the police department received an anonymous call regarding past theft at the facility. The complainant reported that they had observed MA A misappropriate medications at the facility. On [DATE] at 03:57 PM officers spoke to the Administrator at the facility and he notified them that the facility had received multiple calls that accused MA A of drug diversion but the Administrator did not believe the allegation because all the med counts had been accurate since MA A started working at the facility. Observation of an undated video and untimed video revealed, MA A injecting Mounjaro into her lower left abdomen in the facility central supply closet. A cabinet with a sign attached that read PLEASE DO NOT PUT OTC MEDS IN THIS CABINET FROM MED AIDE OR NURSES CARTS. PLACE ON CENTRAL SUPPLY. The rest of the texts could not be interpreted because the sheet was torn and folded. In interview on [DATE] at 09:35 AM, the Administrator said in December of 2024 the facility received multiple anonymous complaints that MA A was misappropriating resident medications. He said the calls came daily for several weeks, the police department was notified, and a state surveyor had investigated the incident in 2024. The Administrator reviewed the video and confirmed that MA A appeared in the video and the video was taken in the facility central supply storage. An observation on [DATE] at 09:43 AM of the central supply closet revealed, a cabinet with a sign that read PLEASE DO NOT PUT OTC MEDS IN THIS CABINET FROM MED AIDE OR NURSES CARTS. PLACE ON CENTRAL SUPPLY. The rest of the texts could not be interpreted because the sheet was torn and folded. In an interview on [DATE] at 10:59 AM, MA A said she took injectable medications for weight loss. She said she administered the medications on either Wednesday or Thursday and sometimes she brought them to work. MA A said when she first starting working in the facility at the end of 2024 the facility received multiple calls that alleged she abused residents and misappropriated narcotic medications. She said she was the individual who appeared in the video administering Mounjaro in the central supply room and she sent the video to the individual because she wanted to keep track of her journey. MA A said she used a virtual prescriber so she had no evidence of a prescription or supporting evidence that she legally had access to injectable medications for weight loss. She said the video was shot sometime at the end of 2024 and she brought and administered her Mounjaro to the facility because she was running late and had a schedule for when she administered the medication. MA A said she did not get a special accommodation or notify any staff prior to administering the medication during work hours and in the central supply room. She said she didn't know it was a problem and denied misappropriating resident medications or telling anyone she misappropriated resident medications. MA A said she had not been reported for any kind of misappropriation, she was not suspended at any time during the complaints pending an investigation and the Administrator called her and notified her that the facility investigation and the surveyor investigation found nothing. In an interview on [DATE] at 11:18 AM, the Administrator said when the facility received a complaint for misappropriation the facility should immediately notify the state and start auditing what was suspected to be missing. He said the alleged perpetrator was typically suspended pending investigation. The Administrator said the facility received multiple anonymous tips that MA A was diverting drugs, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 2 of 26 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 11/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some police also received multiple anonymous complaints which resulted in them coming on site to the facility to investigate. He said he received a call from an alleged state surveyor saying they suspected MA A's complaints were due to a disgruntled employee and the state survey agency did not have any concerns about MA A. The Administrator said he sent a message to MA A on [DATE] stating he and the state surveyor thought the complaints were from a disgruntled employee and they found nothing wrong against her. He said the alleged state surveyor, did not come on site, did not provide contact information, did not have an entrance conference or state an intake number they were investigating. The Administrator said he had no evidence that it was a state surveyor that called and in hindsight it probably was not the most legitimate thing. He said MA A had worked on the floor on and off a MA since the facility received the initial tips of alleged drug diversion, she was never suspended, and the facility never restricted her access to medications. LVN A Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication). Record review of the HHSC TULIP on [DATE] revealed, facility staff did not submit report of drug diversion that occurred on [DATE] when 80 controlled substance tablets were stolen. Record review of the facility provided undated investigation record revealed, 80 controlled substance tablets were missing which included:10. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).11. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).12. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).13. 8 tablets of Clonazepam 0.5 mg (anxiety medication).14. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 15. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 16. 8 tablets of Zolpidem 5 mg (sleeping medication).17. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).18. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication).On [DATE] LVN A signed for the 80 controlled substance tablets.On [DATE] the facility performed urine drug screens on only nurses and med aide on day shift and night shift. All staff tested negative except for 1 resident who had a valid prescription for stimulant medications. In an interview on [DATE] at 12:20 PM, RN A said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. She said the nurse was terminated after the incident. In an interview on [DATE] at 12:44 PM, LVN D said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. He said in response facility management drug tested all nurses and MAs and the nurse that left the medication on the counter was terminated after the incident. In an interview on [DATE] at 01:17 PM, the Administrator said after the facility received tips regarding MA As alleged drug diversion, the facility did an audit of the med carts and there was nothing found missing. He said since his limited investigation supported that the complaints appeared to be a disgruntled person he did not report the alleged drug diversion to the state survey agency. The Administrator said after the stolen controlled substances were delivered, they were not documented and then they went missing. The medications were never located, and the facility suspected they were stolen so they performed drug tests on staff. He said the alleged misappropriation by MA A and the stolen controlled substances were not reported because the medication that was stolen did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 3 of 26 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 11/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some belong to a specific resident and was supposed to stock the automated dispensing system it was not a reportable incident. The Administrator said to his knowledge the medications were left on top of the automated dispensing system in the med room. In an interview on [DATE] at 02:07 PM, the Regional Clinical Director said the diverted controlled substances were delivered to stock the automated dispensing system. He said after the incident, nursing staff checked common areas for the missing medications but they did not search personal belongings of residents or staff. The Regional Clinical Director said drug diversion was reportable only when residents medication was missing. He said when a facility received an allegation of misappropriation the staff should be suspended pending investigation, an investigation should be initiated with a count of narcotics to reconcile all controlled substances, staff in-serviced about controlled substances. The Regional Clinical Director said he was never informed of the allegations and investigation into MA A for alleged drug diversion. He said today, he learned the facility received multiple allegations of misappropriation and drug diversion by MA A so she was immediately pulled off the floor and she no longer had access to residents or medication. In an interview on [DATE] at 09:09 AM, LVN A said on Friday, [DATE], she received medications at the nursing station and when the pharmacy delivered medications they came in a big bag with multiple bags within them. She said when the medications arrived sometime between 7-8:00 PM, she left the medications on the counter because at the time she had a resident who expired on her hall, so she was dealing with the death, the mortuary and the family of the expired resident. She said the medications remained unattended on the counter until approximately 4:00 AM towards the end of her shift when she cleaned up and put the big bag in the med room. LVN A said leaving medication on the counter was not out of the normal, everyone did that, and it just happened to be on her shift that someone decided to steal the medications. She said when she realized the controlled medications were missing on her next shift on [DATE] (Saturday), she immediately notified the Weekend Supervisor and they started looking for the medications in the med room, trash can and common areas. She said on the morning of [DATE] (Sunday) she called the Former DON, they searched the facility again and retraced her steps but the medications were never found. LVN A said on [DATE] (Monday) she was asked for written statements and on [DATE] (Tuesday) she was drug tested, interviewed by the corporate team and wrote a second statement. She said the facility told her that someone stole the medications and she was suspended pending further investigation, and she was notified of her termination on [DATE]. LVN A said prior to the drug theft she had never received any training on medication delivery, stocking the automated dispensing system and she had no idea who stole the medication. She said on the night the medication was stolen there were a lot of different people in the building, there were residents, EMS, family, housekeeping, med aides and nurses. In an interview on [DATE] at 10:22 AM, the Weekend Supervisor said she worked on Saturday and Sundays. She said in the morning of [DATE] (Saturday) she was notified by LVN A that she had misplaced the controlled substance so she notified the Former DON and the pharmacy. The Weekend Supervisor said she and LVN C looked through the facility, the medication carts and trash cans but the medications were never found. She said initially LVN A said she left the medications in the nursing station and then she moved it to the medication room and no staff checked the rooms of residents, or the personal belongings of staff or residents. The Weekend Supervisor said the facility drug tested employees, but herself, nursing administration, non-nurse/med aide staff were not drug tested. She said residents were not assessed for side effects of overdose or administration of medications because they were more focused on locating the medications. She said the medications could have been stolen by anyone, it could have been staff, residents of family members. In an interview on [DATE] at 10:53 AM, the Former DON said she started working at the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 4 of 26 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 11/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [DATE] and she was not aware of any allegations of drug diversion or misappropriation made against MA A or any other staff. She said her relationship with MA A was strictly professional, so she didn't know if MA A used weight loss medications but staff were not allowed to administer their own medications in the facility because of potential drug diversion. The Former DON said on [DATE] (Sunday) she was notified that LVN A left controlled substances on the counter on [DATE] and the medication was stolen. She said LVN A assumed someone had put the medication up on [DATE] but she later realized that she left the medication on the counter and never returned to check on it. The Former DON said when she was notified on [DATE] she immediately notified the Administrator and then initiated a search of the building. She said following the advice of the corporate team a drug test was administered to nurses and med aides but nurses in management, CNAs and housekeeping were not tested. The Former DON said she could not say who stole the medications but she didn't see a risk to residents because the residents were asleep. She said unaccounted medications could place residents at risk for potential overdose. The Former DON said when medications were delivered they were to be immediately logged into the automated dispensing system and if staff do not have access the medications should be left with the Unit Manager. In an interview on [DATE] at 11:37 AM, LVN B said on [DATE] she saw LVN A receiving medications at the nursing station. She said when the medications arrived she got what she needed for the 100/400 hall. She said approximately 4 hours later, when she was looking for Tramadol for one of her residents, a coworker notified her that a bag of medication containing the medication was at the nursing station. LVN B said she did not know where LVN A was at that time, but when she returned the next evening LVN A was worried about the missing medication, so they checked the nursing station, med room and the bin containing discontinued medications but the medications were never located. She said staff did not check resident rooms or personal belongings because they didn't think the theft was associated with a resident but on the night of [DATE] LVN A was busy with a new admission, a resident death, waiting for a funeral home and had another resident transitioning. LVN B said unaccounted controlled substances could place residents at risk of drug diversion, and injury or emergency if they ingested the medications. In an interview on [DATE] at 11:59 AM, LVN C said she worked the 6 AM- 6 PM shift on [DATE] (Friday) when the medication was stolen but she stayed late because she had a resident that became unresponsive on her hall. She said LVN A relieved her that night and she observed when LVN A received the medications. LVN C said the next morning (Saturday [DATE]), LVN A had already cleaned up the nursing station, there was no medication left on the counter of the nursing station and she did not know any medications were missing. She said after she returned home on [DATE], LVN A called her to ask her if she saw any medications on the nursing counter and when she returned on Sunday ([DATE]) she along with other staff tried to help LVN A locate the medications. LVN C said during the day of [DATE] she observed medications sitting on the top of the automated dispensing system but she didn't pay any attention to it because at the time she did not know how to restock the medications. She said the medications were never located and the facility never searched resident rooms or personal belongings or assessed residents for potential overdose or ingestion of inappropriate medications. LVN C said unaccounted controlled substances could place residents at risk of overdose and impact the responsible staff professional license. In an interview on [DATE] at 02:49 PM, the Administrator said he was notified of the loss of controlled substances on Monday [DATE]. He said after investigation it was identified that after LVN A signed for the drugs on Friday evening ([DATE]) she left the drugs out on in the nursing station instead of putting it in the automated dispensing system. The Administrator said when LVN A realized she left the medication out, she started calling other nurses to find the medications and then notified the Weekend Supervisor who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 5 of 26 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 11/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some then notified the Former DON. He said after investigation the facility was unable to identify who stole the medication, but nursing staff were trained on receiving medications, stocking the automated dispensing system and drug security. The Administrator said to his knowledge facility staff checked resident rooms but he was not sure, and any staff who had access to the medication carts or med rooms were drug tested. He said the facility failed to drug test everyone who had access to the nursing station and it was an oversight why they didn't test them. He said he failed to investigate all the way through that the medication was at the nursing station and everyone who had access to the building during the time window the theft occurred had access to the medications. The Administrator said unaccounted controlled substances created a risk of a resident self-administering the medications which could lead to overdose and a lot of bad things could happen. He said as the abuse coordinator he was responsible for ensuring all investigations were thorough, making sure corrective actions were in place and incidents are reported appropriately. The Administrator said reporting requirements for an event like this was made by the regional VP and Regional Clinical Director and in this incident he was notified that the drug theft was not a reportable incident. He said failure to report possible drug diversion to the state survey agency would result in the facility not following the correct protocol and the state survey would not be unaware of the incident and could not follow up on it. In an interview on [DATE] at 09:13 AM, the ADON said she was aware of allegations that were made against MA A regarding drug diversion and misappropriation. She said when MA A started working at the facility, they received call continuously every day for weeks that MA A stole resident's pills so the facility audited the controlled substances and no discrepancies were identified. The ADON said MA A was not suspended during the investigation, and the facility just continued auditing the carts during that time. She said the facility never stopped MA A never from administering medications and her access to medication, nursing carts and medication rooms were never interrupted. She said in September of 2025 medications meant for the automated dispensing system came up missing so she was responsible for managing the drug test of specific employees. The ADON said only nurses and MAs were tested, the facility checked the trashcans and she searched some resident rooms but the facility did not do any assessments to identify if any resident gained access to the controlled substances or experienced any side effects of ingestion of the medications. In an interview on [DATE] at 09:39 AM, the Medical Director said he was never notified of alleged drug diversion allegations made against MA A in 2025 because he was not the medical director at the time. He said in 09/2025 he was notified of an incident in which a team member handling narcotics over the weekend did not store them as per the facility policy. He said drug diversion could place residents at risk of uncontrolled pain or consequences of inappropriately administered medications such as overdose. The Medical Director said he was not aware of any residents with uncontrolled pain or missing pain medications. He said no residents were harmed by this incident because all residents received their medications. Record review of the facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property revised 12/2008 revealed, Policy Statement: All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. Policy Interpretation and Implementation: 1.When an incident of theft and or misappropriation of resident property is reported, the Administrator will appoint a staff member to investigate the incident. 2. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 3. The investigation shall consist of at least the following: 1. An interview with the person(s) reporting the missing items; 2. An interview with any witnesses that may have knowledge of the missing items; 3. An interview with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 6 of 26 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 11/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident (as medically appropriate); 4. An interview with the employee (if any) accused of taking the resident's property; 5. A review of the resident's personal inventory record to determine if the missing items were recorded on the report; 6. Interviews with staff members (on all shifts) having contact with the resident during the past 48 hours; 7. Interviews with the resident's roommate, family members, and visitors; 8. A search of the laundry room for missing articles of clothing; and 9. A search of the resident's room for the missing items. 4. Should an alleged or suspected case of misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: 1. State Licensing and Certification Agency; 2. Ombudsman; 3. Resident Representative; 4. Adult Protective Services;5. Law Enforcement Officials; 5.While the investigation is being conducted, accused individuals not employed by the facility may be denied unsupervised access to the resident. Visits may only be made in designated areas. 6. Employees of this facility who have been accused of misappropriating resident property will be reassigned to non-resident contact duties or suspended without pay until the results of the investigation have been reviewed by the Administrator and a determination of action(s) to be taken has been made. 9.The Administrator will report the results of the investigation to the local police department, the ombudsman, and to the state survey and certification agency within five (5) working days of the incident. Record review of the Administrator's Job Description revised 2003 revealed, The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Record review of the facility policy titled Administrator revised in 04/2007 revealed, 1. The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: Managing the day-to-day functions of the facility; Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities; Record review of the facility policy titled Conformity with Laws and Professional Standards revised in 04/2007 revealed, Policy Statement: Our facility operates and provides services in compliance with current federal, state, and local laws, regulations, codes and professional standards of practice that apply to our facility and types of services provided. Policy Interpretation and Implementation: 1. Our facility is in conformity with all federal, state, and local laws relating to fire safety and disaster pre-preparedness, sanitation, communicable and reportable diseases, postmortem procedures, resident rights and confidentiality of information as well as other relevant health and safety requirements. Record review of the facility policy titled Unusual Occurrence Reporting revised in 12/2007 revealed, Policy Statement: As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Policy Interpretation and Implementation: 1. Our facility will report the following events to appropriate agencies: g. Allegations of abuse, neglect and misappropriation of resident property; andh. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 7 of 26 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 11/24/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. 4. The administration will keep a copy of written reports on file. Record review of the facility policy tilted Abuse Investigation revised 04/2010 revealed, no instructions on how to investigate or report drug diversion. Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 1. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7. The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers. Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1. All staff shall follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services. Policy Interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2. Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt. 4. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors. 5. The delivery ticket shall be archived in a designated location. 6. The dispensing pharmacy, consultant pharmacist, and Director of Nursing Services shall be not[TRUNCATED] Event ID: Facility ID: 676165 If continuation sheet Page 8 of 26 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 11/24/2025 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 0610 Respond appropriately to all alleged violations. 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 that all alleged violations involving abuse, neglect and injury of unknown origin, are thoroughly investigated and results reported of all investigations to the State Survey Agency, within 5 working days of the incident for 1 of 1 facility reviewed for misappropriation. - The facility Administrator failed to thoroughly investigate, put corrective actions in place and to report the results of the investigation to the state agency within 5 working days of the incident following allegations of drug theft and misappropriation of resident property by MA A - The facility Administrator failed to thoroughly investigate, put appropriate corrective actions in place and to report the results of the investigation to the state agency within 5 working days of the incident following drug theft of 80 controlled substance tablets that occurred on [DATE]. These failures could place residents at risk of drug diversion and misappropriation. Findings Include: MA A Record review of the facility's employee records revealed, MA A's date of hire was [DATE] and she was hired as a medication aide. Record review of the Administrator's Internal Investigation Report signed by the Administrator and ADON on [DATE] revealed, employee name: MA A; Date of Incident Report: [DATE]; Investigator: Administrator; Additional Participants: ADON. Summary of Allegations: On [DATE], the facility received multiple anonymous phone calls alleging that [MA A] was stealing medications. The caller specifically asked if the facility employed her and claimed she had been taking medications from the carts. These calls were very short and the caller refused to leave a name or how she knew of this information. Immediate Actions Taken: Medication Audit- [ADON] immediately conducted a thorough audit of all medication cart; Result: No missing or unaccounted medications were found. Law Enforcement Involvement: On [DATE], officers from the [police department] entered the facility requested to speak with the Administrator regarding similar anonymous reports. The Administrator confirmed to officers that internal audit had been completed with no discrepancies. The police interviewed [MA A] on-site. Following the interview, law enforcement expressed no ongoing concerns and took no further action. Findings: No missing medications were identified. There is no evidence supporting the allegation of theft or diversion. The allegations appear to be malicious in nature, potentially made by an individual known to [MA A] from a previous place of employment. Conclusion: Based on the internal audit, staff interviews, and law enforcement input, there is no substantiated evidence of medication diversion or misconduct by [MA A]. No further investigation is warranted at this time. Corrective/Preventative Measures: continued routine medication carts audits will be performed. Staff reminded to immediately report any concerns of potential diversion. Documentation of this investigation will be retained in the Administrator's reference. The file did not include evidence of : interviews of staff, including MA A regarding the alleged drug diversion; documented medication audits; resident interviews, law enforcement notification; reassignment of MA A, state survey agency notification. Record review of the HHSC TULIP (system to which providers report accidents and incidents) on [DATE] revealed, multiple anonymous complaints were submitted that alleged MA A misappropriated multiple resident medications and items. The facility did not submit any Facility Reported Incidents regarding alleged misappropriation by MA A. Record review of Police Department Call Record Dated [DATE] revealed, on [DATE] at 03:26 PM the police department received an anonymous call regarding past theft at the facility. The complainant reported that they had observed MA A misappropriate medications at the facility. On [DATE] at 03:57 PM officers spoke to the Administrator at the facility and he notified them that the facility had received multiple calls that accused MA A of drug diversion but the Administrator did not believe the allegation because all the med counts had been accurate since MA A started working at the facility. Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 9 of 26 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 11/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of an undated social media app chat conversation at 09:39 AM revealed, MA As status was active 1 h ago. MA A sent a 14 second video of her injecting Mounjaro (an injectable weight loss medication) into her lower left abdomen. In response the unknown individual responding, What are you doing pook MA A responded Mounjaro. I wanna get my own script but until I can afford the facility gone supply this shit , to which the unknown induvial responded Oh ok. Observation of an undated video and untimed video revealed, MA A injecting Mounjaro into her lower left abdomen in the facility central supply closet. A cabinet with a sign attached that read PLEASE DO NOT PUT OTC MEDS IN THIS CABINET FROM MED AIDE OR NURSES CARTS. PLACE ON CENTRAL SUPPLY. The rest of the texts could not be interpreted because the sheet was torn and folded. In interview on [DATE] at 09:35 AM, the Administrator said in December of 2024 the facility received multiple anonymous complaints that MA A was misappropriating resident medications. He said the calls came daily for several weeks, the police department was notified and a state surveyor had investigated the incident in 2024. The Administrator reviewed the video and confirmed that MA A appeared in the video and the video was taken in the facility central supply storage. An observation on [DATE] at 09:43 AM of the central supply closet revealed, a cabinet with a sign that read PLEASE DO NOT PUT OTC MEDS IN THIS CABINET FROM MED AIDE OR NURSES CARTS. PLACE ON CENTRAL SUPPLY. The rest of the texts could not be interpreted because the sheet was torn and folded. In an interview on [DATE] at 10:59 AM, MA A said she took injectable medications for weight loss. She said she administered the medications on either Wednesday or Thursday and sometimes she brought them to work. MA A said when she first starting working in the facility at the end of 2024 the facility received multiple calls that alleged she abused residents and misappropriated narcotic medications. She said she was the individual who appeared in the video administering Mounjaro in the central supply room and she sent the video to the individual because she wanted to keep track of her journey. MA A said she used a virtual prescriber so she had no evidence of a prescription or supporting evidence that she legally had access to injectable medications for weight loss. She said she said the video was shot sometime at the end of 2024 and she brought and administered her Mounjaro to the facility because she was running late and had a schedule for when she administered the medication. MA A said she did not get a special accommodation or notify any staff prior to administering the medication during work hours and in the central supply room. She said she didn't know it was a problem and denied misappropriating resident medications or telling anyone she misappropriated resident medications. MA A said she had not been reported for any kind of misappropriation, she was not suspended at any time during the complaints pending investigation and the Administrator called her and notified her that the facility investigation and the alleged state surveyor investigation found nothing. In an interview on [DATE] at 11:18 AM, the Administrator said when the facility received a complaint for misappropriation the facility should immediately notify the state and start auditing what is suspected to be missing. He said the alleged perpetrator was typically suspended pending investigation. The Administrator said the facility received multiple anonymous tips that MA A was diverting drugs, the police also received multiple anonymous complaints which resulted in them coming on site to the facility to investigate and he received a call from an alleged state surveyor saying they suspected MA As complaints were due to a disgruntled employee and the state survey agency did not have any concerns about MA A. The Administrator said he sent a message to MA A on [DATE] stating he and the state surveyor thought the complaints were from a disgruntled employee and they found nothing wrong against her. He said the alleged state surveyor, did not come on site, did not provide contact information, did not have an entrance conference or state an intake number they were investigation. The Administrator said he had no evidence that it was a state surveyor that called and in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 10 of 26 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 11/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hindsight it probably was not the most legitimate thing. He said MA A had worked on the floor on and off a MA since the facility received the initial tips of alleged drug diversion, she was never suspended and the facility never restricted her access to medications. LVN A Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication). Record review of the HHSC TULIP (system to which providers report accidents and incidents) on [DATE] revealed, facility staff did not submit report of drug diversion that occurred on [DATE] when 80 controlled substance tablets were stolen. Record review of the facility provided undated investigation record revealed, 80 controlled substance tablets were missing which included:1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication).On [DATE] LVN A signed for the 80 controlled substance tablets.On [DATE] the facility performed urine drug screens on only nurses and med aide on day shift and night shift. All staff tested negative except for 1 resident who had a valid prescription for stimulant medications. In an interview on [DATE] at 12:20 PM, RN A said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. She said the nurse was terminated after the incident. In an interview on [DATE] at 12:44 PM, LVN D said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. He said in response facility management drug tested all nurses and CMAs and the nurse that left the medication on the counter was terminated after the incident. In an interview on [DATE] at 01:17 PM, the Administrator said after the facility received tips regarding MA As alleged drug diversion, the facility did an audit of the med carts and there was nothing found missing. He said since his limited investigation supported that the complaints appeared to be a disgruntled person he did not report the alleged drug diversion to the state survey agency. The Administrator said after the stolen controlled substances were delivered, they were not documented and then they went missing. The medications were never located, and the facility suspected they were stolen so they performed drug tests on staff. He said the alleged misappropriation by MA A and the stolen controlled substances were not reported because the medication that was stolen did not belong to a specific resident and was supposed to stock the automated dispensing system it was not a reportable incident. The Administrator said to his knowledge the medications were left on top of the automated dispensing system in the med room. In an interview on [DATE] at 02:07 PM, the Regional Clinical Director said the diverted controlled substances were delivered to stock the automated dispensing system. He said after the incident, nursing staff checked common areas for the missing medications but they did not search personal belongings of residents or staff. The Regional Clinical Director said drug diversion was reportable only when a residents medication was missing. He said when a facility received an allegation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 11 of 26 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 11/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of misappropriation the staff should be suspended pending investigation, an investigation should be initiated with a count of narcotics to reconcile all controlled substances, staff in-serviced about controlled substances. The Regional Clinical Director said he was never informed of the allegations and investigation into MA A for alleged drug diversion. He said today, he learned the facility received multiple allegations of misappropriation and drug diversion by MA A so she was immediately pulled off the floor and she no longer had access to residents or medication. In an interview on [DATE] at 09:09 AM, LVN A said on Friday, [DATE], she received medications at the nursing station and when the pharmacy delivered medications they came in a big bag with multiple bags within them. She said when the medications arrived sometime between 7-8:00 PM she left the medications on the counter because at the time she had a resident who expired on her hall, so she was dealing with the death, the mortuary and the family of the expired resident. She said the medications remained unattended on the counter until approximately 4:00 AM towards the end of her shift when she cleaned up and put the big bag in the med room. LVN A said leaving medication on the counter was not out of the normal, everyone did that, and it just happened to be on her shift that someone decided to steal the medications. She said when she realized the controlled medications were missing on her next shift on [DATE] (Saturday), she immediately notified the Weekend Supervisor and they started looking for the medications in the med room, trash can and common areas. She said on the morning of [DATE] (Sunday) she called the Former DON, they searched the facility again and retraced her steps but the medications were never found. LVN A said on [DATE] (Monday) she was asked for written statements and on [DATE] (Tuesday) she was drug tested, interviewed by the corporate team and wrote a second statement. She said the facility told her that someone stole the medications and she was suspended pending further investigation, and she was notified of her termination on [DATE]. LVN A said prior to the drug theft she had never received any training on medication delivery, stocking the automated dispensing system and she had no idea who stole the medication. She said on the night the medication was stolen there were a lot of different people in the building, there were residents, EMS, family, housekeeping, med aides and nurses. In an interview on [DATE] at 10:22 AM, the Weekend Supervisor said she worked on Saturday and Sundays. She said in the morning of [DATE] (Saturday) she was notified by LVN A that she had misplaced the controlled substance so she notified the Former DON and the pharmacy. The Weekend Supervisor said she and LVN C looked through the facility, the medication carts and trash cans but the medications were never found. She said initially LVN A said she left the medications in the nursing station and then she moved it to the medication room and no staff checked the rooms of residents, or the personal belongings of staff or residents. The Weekend Supervisor said the facility drug tested employees, but herself, nursing administration, non-nurse/med aide staff were not drug tested. She said residents were not assessed for side effects of overdose or administration of medications because they were more focused on locating the medications. She said the medications could have been stolen by anyone, it could have been staff, residents of family members. In an interview on [DATE] at 10:53 AM, the Former DON said she started working at the facility on [DATE] and she was not aware of any allegations of drug diversion or misappropriation made against MA A or any other staff. She said her relationship with MA A was strictly professional, so she didn't know if MA A used weight loss medications but staff were not allowed to administer their own medications in the facility because of potential drug diversion. The Former DON said on [DATE] (Sunday) she was notified that LVN A left controlled substances on the counter on [DATE] and the medication was stollen. She said LVN A assumed someone had put the medication up on [DATE] but she later realized that she left the medication on the counter and never returned to check on it. The Former DON said when she was notified on [DATE] she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 12 of 26 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 11/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some immediately notified the Administrator and then initiated a search of the building. She said following the advice of the corporate team a drug test was administered to nurses and med aides but nurses in management, CNAs and housekeeping were not tested. The Former DON said she could not say who stole the medications but she didn't see a risk to residents because the residents were asleep. She said unaccounted medications could place residents at risk for potential overdose. The Former DON said when medications were delivered they were to be immediately logged into the automated dispensing system and if staff do not have access the medications should been left with the Unit Manager. In an interview on [DATE] at 11:37 AM, LVN B said on [DATE] she saw LVN A receiving medications at the nursing station. She said when the medications arrived she got what she needed for the 100/400 hall. She aid approximately 4 hours later, when she was looking for Tramadol for one of her residents, a coworker notified her that a bag of medication containing the medication was at the nursing station. LVN B said she did not know where LVN A was at that time, but when she returned the next evening LVN A was worried about the missing medication, so they checked the nursing station, med room and the bin containing discontinued medications but the medications were never located. She said staff did not check resident rooms or personal belongings because they didn't think the theft was associated with a resident but on the night of [DATE] LVN A was busy with a new admission, a resident death, waited for a funeral home and had another resident transitioning. LVN B said unaccounted controlled substances could place residents at risk of drug diversion, and injury or emergency if they ingested the medications. In an interview on [DATE] at 11:59 AM, LVN C said she worked the 6 AM- 6 PM shift on [DATE] (Friday) when the medication was stolen but she stayed late because she had a resident that became unresponsive on her hall. She said LVN A relieved her that night and she observed when LVN A received the medications. LVN C said the next morning (Saturday [DATE]), LVN A had already cleaned up the nursing station, there was no medication left on the counter of the nursing station and she did not know any medications were missing. She said after she returned home on [DATE], LVN A called her to ask her if she saw any medications on the nursing counter and when she returned on Sunday ([DATE]) she along with other staff tried to help LVN A locate the medications. LVN C said during the day of [DATE] she observed medications sitting on the top of the automated dispensing system but she didn't pay any attention to it because at the time she did not know how to restock the medications. She said the medications were never located and the facility never searched resident rooms or personal belongings or assessed residents for potential overdose or ingestion of inappropriate medications. LVN C said unaccounted controlled substances could place residents at risk of overdose and impact the responsible staff professional license. In an interview on [DATE] at 02:49 PM, the Administrator said he was notified of the loss of controlled substances on Monday [DATE]. He said after investigation it was identified that after LVN A signed for the drugs on Friday evening ([DATE]) she left the drugs out on in the nursing station instead of putting it in the automated dispensing system. The Administrator said when LVN A realized she left the medication out, she started calling other nurses to find the medications and then notified the Weekend Supervisor who then notified the Former DON. He said after investigation the facility was unable to identify who stole the medication, but nursing staff were trained on receiving medications, stocking the automated dispensing system and drug security. The Administrator said to his knowledge facility staff checked resident rooms but he was not sure, and any staff who had access to the medication carts or med rooms were drug tested. He said the facility failed to drug test everyone who had access to the nursing station and it was an oversight why they didn't test them. He said he failed to investigate all the way through that the medication was at the nursing station and everyone who had access to the building during the time window the theft (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 13 of 26 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 11/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some occurred had access to the medications. The Administrator said unaccounted controlled substances created a risk of a resident self-administering the medications which could lead to overdose and a lot of bad things could happen. He said as the abuse coordinator he was responsible for ensuring all investigations were thorough, making sure corrective actions were in place and incidents are reported appropriately. The Administrator said reporting requirements for an event like this was made by the regional VP and Regional Clinical Director and in this incident he was notified that the drug theft was not a reportable incident. He said failure to report possible drug diversion to the state survey agency would result in the facility not following the correct protocol and the state survey would not be unaware of the incident and could not follow up on it. The Administrator said following the incident the facility in-serviced only MAs, LVNs and RNs on medication storage, restocking the automated dispensing system, controlled substances and the delivery/receipt of medication. He said he did not complete a thorough investigation about MA A's alleged drug diversion. He said while the facility completed medication audits to confirm nothing was checked, there was no documentation of the audits, there were no staff or resident interviews about potential misappropriation. The Administrator going forward, if an allegation of drug diversion or misappropriation was made the police would be notified immediately, interviews would start immediately, and the facility would be placed almost in a lockdown mode to ensure resident safety and to ensure no one is walking away with medication. He would investigate who was in the building, talk to every single person in the building, residents would be monitored per the recommendation of the clinical team and everything would be documented in his records or PCC. The administrator said failure to complete a thorough investigation could result in the facility not having answers or knowing what fell short and what to address in the future like corrective actions, training or education. He said failure to investigate incidents like drug theft and misappropriation could place residents tat risk of adverse reactions if the resident took the medication and drug diversion. The administrator said he fell short in documentation of the facility incidents regarding drug diversion In an interview on [DATE] at 09:13 AM, the ADON said she was aware of allegations that were made against MA A regarding drug diversion and misappropriation. She said when MA A started working at the facility they received call continuously every day for weeks that MA A stole resident's pills so the facility audited the controlled substances and no discrepancies were identified. The ADON said MA A was not suspended during the investigation, and the facility just continued auditing the carts during that time. the facility never stopped MA A never from administering medications and her access to medication, nursing carts and medication rooms were never interrupted. She said in September of 2025 medications meant for the automated dispensing system came up missing so she was responsible for managing the drug test of specific employees. The ADON said only nurses and MAs were tested, the facility check the trashcans and she searched some resident rooms but the facility did not do any assessments to identify if any resident gained access to the controlled substances or experienced any side effects of ingestion of the medications. In an interview on [DATE] at 09:39 AM, the Medical Director said he was never notified of alleged drug diversion allegations made against MA A in 2025 because he was not the medical director at the time. He said in 09/2025 he was notified of an incident in which a team member handling narcotics over the weekend did not store them as per the facility policy. He said drug diversion could place residents at risk of uncontrolled pain or consequences of inappropriately administered medications such as overdose. The Medical Director said he was not aware of any residents with uncontrolled pain or missing pain medications. He said no residents were harmed by this incident because all residents received their medications. Record review of the facility policy titled Administrator revised in 04/2007 revealed, 1. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 14 of 26 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 11/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: Managing the day-to-day functions of the facility; Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities; Record review of the facility policy titled Unusual Occurrence Reporting revised in 12/2007 revealed, Policy Statement: As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Policy Interpretation and Implementation: 1. Our facility will report the following events to appropriate agencies: g. Allegations of abuse, neglect and misappropriation of resident property; andh. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. 4. The administration will keep a copy of written reports on file. Record review of the facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property revised 12/2008 revealed, Policy Statement: All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. Policy Interpretation and Implementation: 1.When an incident of theft and or misappropriation of resident property is reported, the Administrator will appoint a staff member to investigate the incident. 2. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 3. The investigation shall consist of at least the following: 1. An interview with the person(s) reporting the missing items; 2. An interview with any witnesses that may have knowledge of the missing items; 3. An interview with the resident (as medically appropriate); 4. An interview with the employee (if any) accused of taking the resident's property; 5. A review of the resident's personal inventory record to determine if the missing items were recorded on the report; 6. Interviews with staff members (on all shifts) having contact with the resident during the past 48 hours; 7. Interviews with the resident's roommate, family members, and visitors; 8. A search of the laundry room for missing articles of clothing; and 9. A search of the resident's room for the missing items. 4. Should an alleged or suspected case of misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: 1. State Licensing and Certification Agency; 2. Ombudsman; 3. Resident Representative; 4. Adult Protective Services;5. Law Enforcement Officials; 5.While the investigation is being conducted, accused individuals not employed by the facility may be denied unsupervised access to the resident. Visits may only be made in designated areas. 6. Employees of this facility who have been accused of misappropriating resident property will be reassigned to non-resident contact duties or suspended without pay until the results of the investigation have been reviewed by the Administrator and a determination of action(s) to be taken has been made. 9.The Administrator will report the results of the investigation to the local police department, the ombudsman, and to the state survey and certification agency within five (5) working days of the incident. Record review of the facility policy tilted Abuse Investigation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 15 of 26 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 11/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete revised 04/2010 revealed, no instructions on how to investigate or report drug diversion. Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 1. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7. The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers. Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1. All staff shall follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services. Policy Interpretation and Implementation: 1. A nurse shall personally accept each[TRUNCATED] Event ID: Facility ID: 676165 If continuation sheet Page 16 of 26 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 11/24/2025 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to update the facility nursing postings on 10/14/25 and 10/21/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: Observations on Tuesday, 10/14/25, at 08:21 AM and 10:14 AM revealed, the facility Direct Care Report posting on the top of the nursing station facing the front door that read Monday [DATE]. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM) for LVNs, 3 Shifts ( 6AM- 2 PM, 2 PM - 10 PM, 10 PM- 6 AM) for CNAs, 2 shifts for CMAs (6 AM- 2 PM), 2 shifts for Restorative Aides (7:30 AM- 3:30 PM and 8 AM- 4 PM), 1 shift for RN Unit Mangers (8 AM - 4 PM) and 1 shift for RNs (6 PM- 6 AM). The posting indicated the facility census, number of staff types (RN, LVN, CNA, CMA and Restorative Aide) and total hours worked for all shifts. An observation on Tuesday. 10/21/25, at 09:57 AM revealed, the facility Direct Care Report posting on the top of the nursing station facing the front door that read Monday [DATE]. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM) for LVNs, 3 Shifts (6AM- 2 PM, 2 PM - 10 PM, 10 PM- 6 AM) for CNAs, 2 shifts for CMAs (6 AM- 2 PM), 2 shifts for Restorative Aides (7:30 AM3:30 PM and 8 AM- 4 PM), 1 shift for RN Unit Mangers (8 AM - 4 PM) and 1 shift for RNs (6 PM- 6 AM). The posting indicated the facility census, number of staff types (RN, LVN, CNA, CMA and Restorative Aide) and total hours worked for all shifts. In an interview on 10/22/25 at 10:17 AM, the Staffing Coordinator said her daily responsibilities included the daily schedule, managing the on call phone and the direct care report. She said she worked Monday through Friday from 08:00 AM to 05:00 PM and she put out the Direct Care Report daily in the morning when she came into work. The Staffing Coordinator said when she did not work on the weekend the Weekend Supervisor was responsible for it on the weekend. She said the Direct Care Report included the name of the facility, date, census type of staff, shifts and the total number of hours scheduled for the day. The Staffing Coordinator said she was not sure what time of the day the nursing posting had to be updated by but if the posting was not updated daily people would not know the staffing or coverage for the building for the day. She said she did not work on Monday 10/14/25 and Monday 10/21/25. She said when she returned from her day off she observed that the nursing posting was the same one she posted on Monday so it was not changed during her absence. The Staffing Coordinator said the DON and the Administrator were responsible for updating the posting when she did not work. In an interview on 10/22/25 at 01:34 PM, the Administrator said the staffing coordinator was responsible for updating the Direct Care Report, when she was absent, Talent or Learning staff made updates, but the DON and Administrator were ultimately responsible to update the staff posting. He said on 10/14/25 and 10/21/25 he was responsible for updating the Direct Care Report because both the Staffing Coordinator and Talent and Learning Staff were absent on those day and he failed to update the posting on those days because it was overlooked. The administrator said failure to update the posting daily could result in people not knowing the facility had adequate coverage and that residents were being taken care of to the best of their ability with appropriate staffing types. Record review of the facility policy Posting Direct Care Daily Staffing Numbers revised 07/2016 revealed, Policy Statement:Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1.The number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly Residents Affected - Many (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 17 of 26 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 11/24/2025 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 0732 Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 3. Shift staffing information shall be recorded on the Daily Nursing Hours Posting form for each shift. The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift. 5. Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator. Event ID: Facility ID: 676165 If continuation sheet Page 18 of 26 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 11/24/2025 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 - Few 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 acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and ensure it had a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that drug records were in order and an account of all controlled drugs was maintained and periodically reconciled for 1 of 10 staff (LVN A) for pharmacy services. - LVN A failed to maintain an accurate inventory of controlled substances when she failed to log into 80 controlled substances into the automated dispensing system on [DATE] which resulted in drug diversion. This failure could result in accurate controlled substance counts and drug diversion. Findings include: Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication). An observation on [DATE] at 09:45 AM revealed, the facility medication room had a keypad controlled access door. There was an automated dispensing system that required credentials to sign in. Record review of the facility provided undated investigation record revealed, 80 controlled substance tablets were missing which included:1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication).On [DATE] LVN A signed for the 80 controlled substance tablets.On [DATE] the facility performed urine drug screens on only nurses and med aide on day shift and night shift. All staff tested negative except for 1 resident who had a valid prescription for stimulant medications. In an interview on [DATE] at 12:20 PM, RN A said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. She said the nurse was terminated after the incident. In an interview on [DATE] at 12:44 PM, LVN D said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. He said in response facility management drug tested all nurses and CMAs and the nurse that left the medication on the counter was terminated after the incident. In an interview on [DATE] at 01:17 PM, the Administrator said after the stolen controlled substances were delivered, they were not documented and then they went missing. The medications were never located, and the facility suspected they were stolen so they performed drug tests on staff. The Administrator said to his knowledge the medications were left on top of the automated dispensing system in the med room In an interview on [DATE] at 02:07 PM, the Regional Clinical Director said the diverted controlled substances were delivered to stock the automated dispensing system. He said after the incident, nursing staff checked common areas for the missing medications but they were never found. In an interview on [DATE] at 09:09 AM, LVN A said on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 19 of 26 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 11/24/2025 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 - Few Friday, [DATE], she received medications at the nursing station and when the pharmacy delivered medications they came in a big bag with multiple bags within them. She said when the medications arrived sometime between 7-8:00 PM she left the medications on the counter because at the time she had a resident who expired on her hall, so she was dealing with the death, the mortuary and the family of the expired resident. She said the medications remained unattended on the counter until approximately 4:00 AM towards the end of her shift when she cleaned up and put the big bag in the med room. LVN A said leaving medication on the counter was not out of the normal, everyone did that, and it just happened to be on her shift that someone decided to steal the medications. She said when she realized the controlled medications were missing on her next shift on [DATE] (Saturday), she immediately notified the Weekend Supervisor and they started looking for the medications in the med room, trash can and common areas. She said on the morning of [DATE] (Sunday) she called the Former DON, they searched the facility again and retraced her steps but the medications were never found. LVN A said on [DATE] (Monday) she was asked for written statements and on [DATE] (Tuesday) she was drug tested, interviewed by the corporate team and wrote a second statement. She said the facility told her that someone stole the medications and she was suspended pending further investigation, and she was notified of her termination on [DATE]. LVN A said prior to the drug theft she had never received any training on medication delivery, stocking the automated dispensing system and she had no idea who stole the medication. She said on the night the medication was stolen there were a lot of different people in the building, there were residents, EMS, family, housekeeping, med aides and nurses. In an interview on [DATE] at 10:22 AM, the Weekend Supervisor said she worked on Saturday and Sundays. She said in the morning of [DATE] (Saturday) she was notified by LVN A that she had misplaced the controlled substance so she notified the Former DON and the pharmacy. The Weekend Supervisor said she and LVN C looked through the facility, the medication carts and trash cans but the medications were never found. She said initially LVN A said she left the medications in the nursing station and then she moved it to the medication room. LVN A said the medications could have been stolen by anyone, it could have been staff, residents of family members. In an interview on [DATE] at 10:53 AM, the Former DON said on [DATE] (Sunday) she was notified that LVN A left controlled substances on the counter on [DATE] and the medication was stollen. She said LVN A assumed someone had put the medication up on [DATE] but she later realized that she left the medication on the counter and never returned to check on it. The Former DON said when she was notified on [DATE] she immediately notified the Administrator and then initiated a search of the building. She said following the advice of the corporate team a drug test was administered to nurses and med aides but nurses in management, CNAs and housekeeping were not tested. The Former DON said she could not say who stole the medications but she didn't see a risk to residents because the residents were asleep. She said unaccounted medications could place residents at risk for potential overdose. The Former DON said when medications were delivered they were to be immediately logged into the automated dispensing system and if staff do not have access the medications should be left with the Unit Manager. In an interview on [DATE] at 11:37 AM, LVN B said on [DATE] she saw LVN A receiving medications at the nursing station. She said when the medications arrived she got what she needed for the 100/400 hall. She aid approximately 4 hours later, when she was looking for Tramadol for one of her residents, a coworker notified her that a bag of medication containing the medication was at the nursing station. LVN B said she did not know where LVN A was at that time, but when she returned the next evening LVN A was worried about the missing medication, so they checked the nursing station, med room and the bin containing discontinued medications but the medications were never located. She said staff did not check resident rooms or personal belongings (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 20 of 26 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 11/24/2025 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 - Few because they didn't think the theft was associated with a resident but on the night of [DATE] LVN A was busy with a new admission, a resident death, waited for a funeral home and had another resident transitioning. LVN B said unaccounted controlled substances could place residents at risk of drug diversion, and injury or emergency if they ingested the medications. In an interview on [DATE] at 11:59 AM, LVN C said she worked the 6 AM- 6 PM shift on [DATE] (Friday) when the medication was stolen but she stayed late because she had a resident that became unresponsive on her hall. She said LVN A relieved her that night and she observed when LVN A received the medications. LVN C said the next morning (Saturday [DATE]), LVN A had already cleaned up the nursing station, there was no medication left on the counter of the nursing station and she did not know any medications were missing. She said after she returned home on [DATE], LVN A called her to ask her if she saw any medications on the nursing counter and when she returned on Sunday ([DATE]) she along with other staff tried to help LVN A locate the medications. LVN C said during the day of [DATE] she observed medications sitting on the top of the automated dispensing system but she didn't pay any attention to it because at the time she did not know how to restock the medications. She said the medications were never located and the facility never searched resident rooms or personal belongings or assessed residents for potential overdose or ingestion of inappropriate medications. LVN C said unaccounted controlled substances could place residents at risk of overdose and impact the responsible staff professional license. In an interview on [DATE] at 02:49 PM, the Administrator said he was notified of the loss of controlled substances on Monday [DATE]. He said after investigation it was identified that after LVN A signed for the drugs on Friday evening ([DATE]) she left the drugs out on in the nursing station instead of putting it in the automated dispensing system. The Administrator said when LVN A realized she left the medication out, she started calling other nurses to find the medications and then notified the Weekend Supervisor who then notified the Former DON. He said after investigation the facility was unable to identify who stole the medication, but nursing staff were trained on receiving medications, stocking the automated dispensing system and drug security. The Administrator said unaccounted controlled substances created a risk of a resident self-administering the medications which could lead to overdose and a lot of bad things could happen. In an interview on [DATE] at 09:39 AM, the Medical Director said in 09/2025 he was notified of an incident in which a team member handling narcotics over the weekend did not store them as per the facility policy. He said drug diversion could place residents at risk of uncontrolled pain or consequences of inappropriately administered medications such as overdose. The Medical Director said he was not aware of any residents with uncontrolled pain or missing pain medications. He said no residents were harmed by this incident because all residents received their medications. In an interview on [DATE] at 01:34 PM, the DON said when controlled substances were delivered they should be counted against the pharmacy record. Resident specific medications should be documented as received with the accompanying control sheet and back up medications scanned and entered into the inventory of the automatic dispensing system. She said accurate documentation of the receipt of controlled substances is necessary to keep a perpetual (never ending) count of medications to ensure there is an accurate account of all controlled substances. The DON said on [DATE] the nurse failed to log medication in the automated dispensing system and failure to keep a proper inventory of controlled substances would result in inaccurate records which could result in the facility being unable to accurately and timely identify drug diversion. Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1. All staff shall follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 21 of 26 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 11/24/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Policy Interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2. Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt. 4. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors. 5. The delivery ticket shall be archived in a designated location. 10. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 1. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7. The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers. Event ID: Facility ID: 676165 If continuation sheet Page 22 of 26 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 11/24/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 10 staff (LVN A) reviewed for medication storage . - LVN A failed to ensure that controlled substances were stored behind a double lock when she left them unattended at the nursing station on [DATE] which resulted in 80 tabs of controlled medication stolen from the facility. This failure could place residents at risk of misappropriation of medications, adverse reactions to medications, overdose and hospitalization. Findings include: Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication). An observation on [DATE] at 09:45 AM revealed, the facility medication room to have a keypad controlled access door. There was an automated dispensing system that required credentials to sign in. Record review of the facility provided undated investigation record revealed, 80 controlled substance tablets were missing which included:1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication).On [DATE] LVN A signed for the 80 controlled substance tablets.On [DATE] the facility performed urine drug screens on only nurses and med aide on day shift and night shift. All staff tested negative except for 1 resident who had a valid prescription for stimulant medications. In an interview on [DATE] at 12:20 PM, RN A said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. She said the nurse was terminated after the incident. In an interview on [DATE] at 12:44 PM, LVN D said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. He said in response facility management drug tested all nurses and CMAs and the nurse that left the medication on the counter was terminated after the incident. In an interview on [DATE] at 01:17 PM, the Administrator said after the stolen controlled substances were delivered, they were not documented and then they went missing. The medications were never located, and the facility suspected they were stolen so they performed drug tests on staff. The Administrator said to his knowledge the medications were left on top of the automated dispensing system in the med room. In an interview on [DATE] at 02:07 PM, the Regional Clinical Director said the diverted controlled substances were delivered to stock the automated dispensing system. He said after the incident, nursing staff checked common areas for the missing medications but they were never found. In an interview on [DATE] at 09:09 AM, LVN A said on Friday, [DATE], she received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 23 of 26 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 11/24/2025 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 medications at the nursing station and when the pharmacy delivered medications they came in a big bag with multiple bags within them. She said when the medications arrived sometime between 7-8:00 PM she left the medications on the counter because at the time she had a resident who expired on her hall, so she was dealing with the death, the mortuary and the family of the expired resident. She said the medications remained unattended on the counter until approximately 4:00 AM towards the end of her shift when she cleaned up and put the big bag in the med room. LVN A said leaving medication on the counter was not out of the normal, everyone did that, and it just happened to be on her shift that someone decided to steal the medications. She said when she realized the controlled medications were missing on her next shift on [DATE] (Saturday), she immediately notified the Weekend Supervisor and they started looking for the medications in the med room, trash can and common areas. She said on the morning of [DATE] (Sunday) she called the Former DON, they searched the facility again and retraced her steps but the medications were never found. LVN A said on [DATE] (Monday) she was asked for written statements and on [DATE] (Tuesday) she was drug tested, interviewed by the corporate team and wrote a second statement. She said the facility told her that someone stole the medications and she was suspended pending further investigation, and she was notified of her termination on [DATE]. LVN A said prior to the drug theft she had never received any training on medication delivery, stocking the automated dispensing system and she had no idea who stole the medication. She said on the night the medication was stolen there were a lot of different people in the building, there were residents, EMS, family, housekeeping, med aides and nurses. In an interview on [DATE] at 10:22 AM, the Weekend Supervisor said she worked on Saturday and Sundays. She said in the morning of [DATE] (Saturday) she was notified by LVN A that she had misplaced the controlled substance so she notified the Former DON and the pharmacy. The Weekend Supervisor said she and LVN C looked through the facility, the medication carts and trash cans but the medications were never found. She said initially LVN A said she left the medications in the nursing station and then she moved it to the medication. LVN A said the medications could have been stolen by anyone, it could have been staff, residents of family members. In an interview on [DATE] at 10:53 AM, the Former DON said on [DATE] (Sunday) she was notified that LVN A left controlled substances on the counter on [DATE] and the medication was stollen. She said LVN A assumed someone had put the medication up on [DATE] but she later realized that she left the medication on the counter and never returned to check on it. The Former DON said when she was notified on [DATE] she immediately notified the Administrator and then initiated a search of the building. She said following the advice of the corporate team a drug test was administered to nurses and med aides but nurses in management, CNAs and housekeeping were not tested. The Former DON said she could not say who stole the medications but she didn't see a risk to residents because the residents were asleep. She said unaccounted medications could place residents at risk for potential overdose. The Former DON said when medications were delivered they were to be immediately logged into the automated dispensing system and if staff do not have access the medications should be left with the Unit Manager. In an interview on [DATE] at 11:37 AM, LVN B said on [DATE] she saw LVN A receiving medications at the nursing station. She said when the medications arrived she got what she needed for the 100/400 hall. She aid approximately 4 hours, when she was looking for Tramadol for one of her residents, a coworker notified her that a bag of medication containing the medication was at the nursing station. LVN B said she did not know where LVN A was at that time, but when she returned the next evening LVN A was worried about the missing medication, so they checked the nursing station, med room and the bin containing discontinued medications but the medications were never located. She said staff did not check resident rooms or personal belongings because they didn't think the theft was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 24 of 26 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 11/24/2025 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 associated with a resident but on the night of [DATE] LVN A was busy with a new admission, a resident death, waited for a funeral home and had another resident transitioning. LVN B said unaccounted controlled substances could place residents at risk of drug diversion, and injury or emergency if they ingested the medications. In an interview on [DATE] at 11:59 AM, LVN C said she worked the 6 AM- 6 PM shift on [DATE] (Friday) when the medication was stolen but she stayed late because she had a resident that became unresponsive on her hall. She said LVN A relieved her that night and she observed when LVN A received the medications. LVN C said the next morning (Saturday [DATE]), LVN A had already cleaned up the nursing station, there was no medication left on the counter of the nursing station and she did not know any medications were missing. She said after she returned home on [DATE], LVN A called her to ask her if she saw any medications on the nursing counter and when she returned on Sunday ([DATE]) she along with other staff tried to help LVN A locate the medications. LVN C said during the day of [DATE] she observed medications sitting on the top of the automated dispensing system but she didn't pay any attention to it because at the time she did not know how to restock the medications. She said the medications were never located and the facility never searched resident rooms or personal belongings or assessed residents for potential overdose or ingestion of inappropriate medications. LVN C said unaccounted controlled substances could place residents at risk of overdose and impact the responsible staff professional license. In an interview on [DATE] at 02:49 PM, the Administrator said he was notified of the loss of controlled substances on Monday [DATE]. He said after investigation it was identified that after LVN A signed for the drugs on Friday evening ([DATE]) she left the drugs out on in the nursing station instead of putting it in the automated dispensing system. The Administrator said when LVN A realized she left the medication out, she started calling other nurses to find the medications and then notified the Weekend Supervisor who then notified the Former DON. He said after investigation the facility was unable to identify who stole the medication, but nursing staff were trained on receiving medications, stocking the automated dispensing system and drug security. The Administrator said unaccounted controlled substances created a risk of a resident self-administering the medications which could lead to overdose and a lot of bad things could happen. In an interview on [DATE] at 09:39 AM, the Medical Director said in 09/2025 he was notified of an incident in which a team member handling narcotics over the weekend did not store them as per the facility policy. He said drug diversion could place residents at risk of uncontrolled pain or consequences of inappropriately administered medications such as overdose. The Medical Director said he was not aware of any residents with uncontrolled pain or missing pain medications. He said no residents were harmed by this incident because all residents received their medications. In an interview on [DATE] at 01:34 PM, the DON said controlled medications should be stored behind a double lock regardless of it being stored in a medication cart or an automated dispensing system to prevent unauthorized entry and to keep residents safe. She controlled substances should be counted against the pharmacy record. Resident specific medications should be documented as received with the accompanying control sheet and back up medications scanned and entered into the inventory of the automatic dispensing system. The DON said on [DATE] the nurse failed to timely store medication in the automated dispensing system and the medications should not have been left on the counter. failure to store medications per facility policy could place residents at risk for a change of condition, illness, tiredness and CNS depression (when the brain is slowed down resulting in decreased heart and breathing rates that can cause unconsciousness, coma or death). Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1. All staff shall follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676165 If continuation sheet Page 25 of 26 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 11/24/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete brought to the attention of the Pharmacist and Director of Nursing Services. Policy Interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2. Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt. 4. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors. 5. The delivery ticket shall be archived in a designated location. 6. The dispensing pharmacy, consultant pharmacist, and Director of Nursing Services shall be notified of medication order errors. 10. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. 11. The Director of Nursing Services shall consult with the provider pharmacy and the Administrator to determine whether any further legal action is indicated. 12. In the event there is concern about controlled substances being discharged with the resident and/or resident's representative, the Attending Physician may choose not to discharge the resident with those medications. 13. The Director of Nursing Services shall maintain and disseminate to appropriate individuals a list of personnel who have access to medication storage areas and controlled substance containers. Record review of the facility policy titled Storage of Medication revised 04/2007 revealed, Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 1. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7. The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers. Event ID: Facility ID: 676165 If continuation sheet Page 26 of 26