Health inspection·July 14, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 07/12/2023 at 12:44 PM revealed Resident #86 was sitting on the side of her bed eating lunch. Resident #86 stated she was good. The resident stated she had everything she needed. Resident #86 stated she did not want to talk to any one any longer. In an interview on 07/14/2023 at 8:35AM LVN A stated she has worked in the facility for a month. LVN A stated she has worked with Resident #86 two times. LVN A stated she was aware of Resident #86's diagnoses from review of the resident's clinical record. LVN A stated she read the resident's notes, care plans and talked with the resident to assess the resident's mental status. In an interview on 07/14/2023 at 9:18 AM LVN B stated she did participate in the development of the resident care plan as the MDS nurse. LVN B stated multiple departments participated in the development of the care plan. LVN B stated the purpose of the care plan was a [NAME] for the plan of care for the resident. The LVN B continued and stated the care plan should include anything that could create a problem for the resident. LVN B stated yes Resident #86's diagnoses should be included in the care plan. The LVN B stated the DON was responsible for monitoring the accuracy of the care plan. LVN B stated the risk of an inaccurate care plan was it could provide an inaccurate picture of the resident which could result in a delay in care. LVN B stated Resident #86's diagnoses were missed because she was here for short term care. LVN B stated there was a standard of care for the short-term residents. The standard of care address the same issues that are care planned. Resident # 86 did not have any symptoms for the diagnoses. LVN B stated to prevent this again the standard of care should be included in the comprehensive care plan. In an interview on 07/14/2023 at 9:42AM the DON stated the purpose of the care plan was to highlight the care needed for the resident. The DON stated it was important to care plan the diagnoses for resident care. The DON stated the development of the care plan was interdisciplinary to include all department heads. The DON stated the MDS department was responsible for monitoring care plan accuracy. The DON stated the risk of an inaccurate care plan was the effect on the resident care. In an interview on 07/14/2023 at 10:41 AM the Administrator stated the purpose of the resident care plan was to make sure the resident received the required care. The Administrator stated for a long-term resident the diagnoses of schizoaffective disorder and delusional disorder needed to be care planned. The Administrator stated there was a standard of practice for the short-term resident. The Administrator stated he and the DON were responsible for monitoring care plan accuracy in the morning meetings for resident changes. The Administrator stated an inaccurate care-plan could have a negative effect on the resident care. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered Revised dated December 2016, reflected in part Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 2 of 7 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 676273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of the Woodlands 1014 Windsor Lake Boulevard The Woodlands, TX 77384 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation the facility failed to ensure residents received drinks consistent with preference and sufficient to maintain hydration for 10 of 10 (confidential group) and 3 of 21 (Resident #1, Resident #2, and Resident # 78) of residents reviewed for hydration. The facility did not provide hot coffee to residents during mealtimes. This failure could place residents who depend on the facility for their hydration needs at risk for thirst, dehydration, and decreased quality of life. Findings included: Record review Resident #1's face sheet revealed resident admitted to the facility on [DATE]. Resident #1's was diagnosed with essential (primary) hypertension, type 2 diabetes mellitus without complications, cerebral infarction, unspecified, spinal stenosis (space inside the backbone is too small placing pressure on the spinal cord and nerves), site unspecified, muscle weakness (generalized), unspecified atrial fibrillation (irregular heart beat), benign prostatic hyperplasia with lower urinary tract symptom (weak urine stream causing frequent urination), narcissistic personality disorder (inflated sense of self-importance), other recurrent depressive disorders, insomnia, unspecified nicotine dependence, unspecified, uncomplicated, adult failure to thrive (decline and health and ability), and pain, unspecified. Record review of Resident #1's care plan dated 06/05/23 revealed resident had ADL self-care performance deficit with limited mobility. Record review of Resident #1's admission MDS dated [DATE], revealed Resident #1's BIMS was scored as 13 which indicated his cognition was intact. Resident #1's active diagnoses included medically complex condition. Record review of Resident #2's face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE]. The resident was diagnosed with unspecified fall, subsequent encounter, encounter for other specified surgical aftercare, essential (primary) hypertension, type 2 diabetes mellitus without complications, elevated white blood cell count, benign prostatic hyperplasia with lower urinary tract symptoms (weak urine stream causing frequent urination), hyperlipidemia (hardening of the arteries), unspecified), pain, unspecified, presence of left artificial knee joint, encounter for other orthopedic aftercare, aftercare following joint replacement surgery. Record review Resident #2 care plan dated revealed Resident #2's was at risk for weight fluctuations due to his changes in appetite, and difficulty adjusting to new environment from recent hospitalization. Record review of Resident #2's admission MDS dated [DATE], revealed Resident #2's BIMS was scored as 14 which indicated his cognition was intact. Resident #2's active diagnoses included hip and knee replacement. Record review of Resident #78's face sheet revealed a [AGE] year-old male who admitted into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 3 of 7 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 676273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of the Woodlands 1014 Windsor Lake Boulevard The Woodlands, TX 77384 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 0807 Level of Harm - Minimal harm or potential for actual harm facility on [DATE]. The resident was diagnosed with dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, overactive bladder, constipation, unspecified anemia, unspecified, pain, unspecified, gastro-esophageal reflux disease without esophagitis (inflammation of the esophagus/throat), other muscle spasm, insomnia, unspecified, dehydration, Alzheimer's disease with late onset. Residents Affected - Some Record review of Resident #78's care plans dated 05/04/2023 revealed Resident #78 had the potential for fluid volume deficit with medication side effects. Record review of Resident #78's admission MDS dated [DATE], revealed Resident #78's BIMS scored of 12 indicates moderate cognitive impairment. Resident #78's active diagnoses included traumatic brain disfunction. Observation on 07/12/23 at 08:43 AM Resident #2 observed in the activities room sitting in his wheelchair in front of the television drinking coffee from a white styrofoam cup. Interview on 07/11/23 at 08:55 AM Resident #78 stated that his coffee is always cold at every mealtime every day. He told staff (could not provide exact dates, names, or titles) his coffee is always cold, but they do not do anything about it. Interview on 07/11/23 at 10:00 AM Resident #1 stated that coffee is always cold at every mealtime every day. He told staff (could not provide exact dates, names, or titles) his coffee is always cold and asked for a fresh hot cup. Interview on 07/11/23 at 10:02 AM Resident #2 stated that the facility does not serve hot coffee. He stated he has to go all the way down to the activities room to get a fresh hot cup of coffee. He stated some days he is too tired and does not have the energy to wheelchair himself down to the activities room on at the end of hall-3 from his room on hall-4, especially after physical therapy. Interview on 07/12/23 at 08:43 AM Resident #2 stated he received coffee on his breakfast tray this morning, but it was not hot and did not taste good. He stated he comes to the activities room to get hot cups of coffee. He stated it is not always easy for him to get to the activities room when he is feeling weak and/or tired especially on days when he has had therapy. Interview on 07/12/23 at 09:33 AM AD stated that at the monthly resident council's meetings the resident's regularly complain of cold food and coffee and the Administrator and DM address every time. Interview on 07/12/23 at 10:15 AM during the confidential resident council meeting, 10 of 10 residents stated that they did not receive hot coffee during mealtimes on a consistent basis. Coffee is poured by the CNAs on each hall. The coffee must sit for a while before being poured. If they are lucky, it's hot, but it is often cold or lukewarm at best. Interview on 07/12/23 at 12:27 PM the Administrator stated that he will ensure that hot coffee is available more by speaking with the DM and having her check temperatures and change warm or cold coffee with hot coffee. He stated that the coffee machine was broken recently, and residents were complaining of cold coffee. The coffee machine had since been repaired and he was not aware of any cold coffee complaints until this one. The staff are required to take coffee temperatures before the coffee goes out on the floor. He stated that there is always hot coffee in the dining room at all times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 4 of 7 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 676273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of the Woodlands 1014 Windsor Lake Boulevard The Woodlands, TX 77384 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 07/13/23 at 10:10 AM DM stated she has been the DM for the last five years. She stated she works Monday thru Saturday and most Sundays. She stated she is scheduled to work 7 AM to 4 PM but often comes in early and stays late for her shifts. She stated that the residents have complained of cold coffee in the past. She stated and for that reason, kitchen staff no longer serve coffee on the trays to avoid serving cold coffee. She stated that two coffee urns are filled with coffee for each of the 4 halls. Coffee temperatures are taken prior to the coffee leaving the kitchen and logged on the coffee temperature log before the breakfast, lunch, and dinner meals. She stated the two urns are placed on top of each of the food carts. She stated once the carts are on the hall, the CNAs are responsible for pouring coffee for the residents who desire coffee and who have no coffee dietary restrictions. She stated that she had coffee temp logs for May 2023, June 2023 and July 2023 and would provide copies along with the coffee temp policy. Record review of the facility's Grievance QA Log dated May 2023: Date of Grievance 05/17/2023. Grievance: Coffee Temperature. Resident's Name: Resident Council. Following Investigation: Date 05/17/2023. Person Assigned: AIT. Resolution: Monitoring Temp with thermometer. Date Complainant Notified 05/17/0223. Record review of Grievance/Complaint Report dated 05/17/2023. Received by AD. Resident Representative: Resident Council. Following investigation Date: 05/15/2023 Person Assigned: AIT. Manager Meeting. Tested coffee on hall with thermometer. Resident Council informed of temperature results at next council meeting. Form completed by AIT. Record review of Grievance QA Log dated June 2023: Date of Grievance 06/08/2023. Grievance: Dietary Concern. Resident's Name: Resident Council. Following investigation Date: 06/09/2023 Person Assigned: DM. Resolution: 1:1 with staff. Discussed with Residents. Date Complainant Notified: 06/09/2023. Record review of Grievance/Complaint Report dated 06/08/2023. Received by AD. Resident representative: Resident Council. Documentation of Grievance/Complaint: Dietary Concerns. Documentation of Facility Follow-up: Manager meeting discussed concerns. DM addressed concerns with residents. Coffee maker was broken and fixed. Resolution of Grievance Dated 06/09/2023: Coffee maker fixed. Discussed with residents. Form completed by SW. Record review In-Service Training Report. Dated 5/2023, From DON Designee to Employee Group: CNAs/Nursing. Topic: ADL documentation/Serve Meals/Cold Coffee. Summary of Training: Ensure Coffee warm enough. Replace warm coffee if it's cold. Conducted by DON. Record review Hot Beverage Temperature Log dated May 2023, June 2023 and July 2023. All temperature range between 130 degrees and 150 degrees. Record review of Policy Code of Federal Regulations SS 483.60 Food and nutrition services. 20. Prior to the point of serve, the temperature of coffee or hot beverage will be checked to ensure temperature is 155F or below. If above 155 F, ice will be added to the coffee until the at or below 155 F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 5 of 7 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 676273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of the Woodlands 1014 Windsor Lake Boulevard The Woodlands, TX 77384 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in 1.The facility failed to ensure that ice scoops will be cleaned and stored in a separate container that limits cross-contamination. 2.The facility failed to ensure that all cold and dry goods items will be stored 6 inches above the floor. These failures could place residents at risk of foodborne illness and disease. Findings included: 1. Observation on 7/13/23 at 8:30 AM with Dietary A revealed that the ice scoop was left in the ice bin on top of the ice. 2. Observation on 7/13/23 at 9:00 AM with the Dining Services Director revealed that dry goods and cold foods were stored 4 inches above the floor. Interview with the Dining Services Director on 7/13/23 at 9:20 AM revealed the ice scoop should not be left in the ice bin. Interview with the Dining Services Director on 7/13/23 at 9:25 AM revealed that dry goods and cold foods will be appropriately stored 6 inches above the floor to ensure that food is not subject to contamination, leakage, rodents or vermin. Record review of Facility 's Policy and Procedure for Ice dated 9/2017 read in part. Ice will be prepared and distributed in a safe and sanitary manner 5. Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention. And or stored in ice machine on holder provided for storage. Record review of Facility's Policy and Procedure Dry Goods and Cold Foods Storage dated 9/2017 read in part. All dry goods and all cold foods will be appropriately stored in accordance with the FDA Food Code rule 228.224 1. All items will be stored on shelves at least 6 inches above the floor 4. The Dining Services Director or designee regularly inspects the dry and cold storage area to ensure it is well lit, well ventilated, and not subject to sewage or wastewater back flow or contamination by condensation, leakage, rodents, or vermin. https://www.dshs.texas.gov/sites/default/files/foodestablishments/pdf/GuidanceDocs/TFER-2021_TAC-228_August-2021.p FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 6 of 7 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 676273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of the Woodlands 1014 Windsor Lake Boulevard The Woodlands, TX 77384 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. Residents Affected - Few -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 07-13-23 at 8:55 am, with the Dining Services Director revealed the facility's dumpster area,was not in use when it was observed to be open which was in the lot behind the dietary department had a commercial -size dumpster and the lid and door were opened. Interview on 07-13-23 at 9:00 am, with the Dining Services Director she stated the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Record review of the facility policy and procedure of Dispose of Garbage and Refuse dated 8/2017 read in part. All garbage and refuse will be collected and disposed of in a safe and efficient manner. 2. The Dining Services Director will ensure that: appropriate lid and door should be closed when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 7 of 7