Health inspection·November 21, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the CNAs randomly monthly and not performing good incontinent care could result in infection, skin break down and UTI. The DON said she did rounds with the nurse aides before the CNA got on the floor to work, also watching them hands on and checked them off on hand washing, incontinent/Foley catheter care. DON said her expectation was for incontinent care was to done well to prevent urinary tract infections and ski break down.Record review of the facility's policy on Perineal Care, revised 6/24/25, reflected: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Event ID: Facility ID: 676273 If continuation sheet Page 2 of 13 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 11/21/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #79) reviewed for incontinent care. 1.The facility failed to ensure CNA B properly cleaned Resident #79's indwelling Foley catheter.2. The facility failed to ensure CNA B followed proper hand hygiene during incontinent care on 9/24/25.3. The facility failed to ensure CNA A secured Resident #79's Foley catheter. These failures could place residents at risk for pain, infection, injury, and hospitalization.Record review of Resident #79's face sheet reflected the date of admission was 8/27/25 and readmitted on [DATE]. Resident #79 had diagnoses which included history of generalized anxiety disorder, other specified depressive episodes, obesity, class 1(excess body fat, other specified hypothyroidism(e03.8), other hyperlipidemia(high lipid/fat in the blood), gastro-esophageal reflux disease without esophagitis, pneumonia due to other specified bacteria, other acute kidney failure, essential (primary) hypertension(high blood pressure), paroxysmal atrial fibrillation (irregular heart beat) obstructive sleep apnea (adult) (pediatric), other specified chronic obstructive pulmonary disease, other insomnia(sleeplessness), other acute osteomyelitis, right ankle and foot, acquired absence of left leg above knee, type 2 diabetes mellitus without complications, chronic systolic (congestive) heart failure, ulcer of anus and rectum, other specified peripheral vascular diseases, acute posthemorrhagic anemia, other hypotension (low blood pressure, acute and chronic respiratory failure with hypoxia.Record review of Resident #79's admission MDS assessment, dated 08/29/2025, Section C (Cognitive Patterns) reflected a BIMS score was 14, which indicated no impairment in thinking. Section H (Bladder and Bowel) reflected the resident had an indwelling catheter. Resident #79's functional status reflected he was independent with supervision of staff with bed mobility, transfer, and toilet use. Resident#79 had an indwelling Foley catheter.Record review of Resident's #79's care plan, dated 9/14/2025, reflected, I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities. I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days. Record review of Resident #79's physician order, dated 8/27/2025, read in part .change Foley catheter with 18-inch catheter and 10cc bulb on the 1st of each month, dated 8/25 . keep catheter from kinks and drainage bag lower than bladder at all times, dated 8/29/25. Observation of incontinent/indwelling Foley catheter on 9/24/25 at 4:14 PM, revealed CNA B performed F/C and incontinent care. CNA B did not wash their hands and did not use hand sanitizer. CNA B donned clean gloves, undid Resident #79's soiled brief, using the wet wipes, cleaned the resident's groin and the F/C was not secured. CNA B did not clean the indwelling catheter; she did not open Resident #79's labia to clean it from the insertion site. Resident #79 had a small BM, CNA A cleaned in -between the buttocks and did not clean around the buttocks, she picked up a clean brief and fastened it on the resident. Interview with C.NA B on 9/24/25 at 4:41 PM, she said she was nervous and did not open the labia to clean the indwelling catheter insertion site. CNA B said not cleaning the indwelling catheter from the insertion site for Resident #79, her hands could cause a UTI, she had an in-service on Foley catheter/incontinent care. Interview with the DON on 9/25/25 at 11:22 PM, she said she did the initial training and would monitor while on the unit. The DON said they monitored the CNAs randomly monthly and not performing good incontinent could result (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 3 of 13 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 11/21/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete in infection and UTI. Record review of the facility's policy for Catheter Care Urinary, date 3/31/2016, reflected: For the female: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. Event ID: Facility ID: 676273 If continuation sheet Page 4 of 13 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 11/21/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #78) reviewed for feeding tubes. The facility staff failed to ensure LVN K verified placement of Resident #78's feeding tube prior to medication administration on 9/23/25. This failure could place residents at risk for complications such as aspiration pneumonia (occurs when food or liquid is breathed into the airway or lungs, instead of being swallowed), pneumothorax (a condition that occurs when air leaks into the space between the lungs and chest wall), perforations, empyema (one of the diseases that compromises chronic obstructive pulmonary disease), bronchopleural fistula (a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space), and/or hospitalization.Record review of Resident #78's admission Assessment reflected an [AGE] year-old male who was admitted to the facility on [DATE] and was readmitted on [DATE]. His diagnoses included gastrostomy tube (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), dysphagia (difficulty swallowing), diagnoses included essential (primary) hypertension ( high blood pressure) other hyperlipidemia (high lipid/fat in the blood) other specified depressive episodes (persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities that were enjoyed) other specified anemias (healthy red blood cells), obesity (unhealthy amount of extra body fat that can lead to serious health problems like heart disease diabetes), class 2, other disorders of plasma protein metabolism (the process where proteins in the blood plasma are continuously broken down into smaller parts [ amino acids] and then rebuilt to form new proteins), not elsewhere classified, narcolepsy without cataplexy (is a sleep disorder characterized by excessive daytime sleepiness and overwhelming urge to sleep) her pulmonary embolism without acute cor pulmonale (deep vein thrombosis [DVT],tumor emboli, fat emboli from broken bones, air emboli or amniotic fluid emboli) from multiple sclerosis (a chronic autoimmune disease where the body's immune system mistakenly attacks the protective covering [myelin] of nerve fibers in the brain and spinal cord), other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere, acute respiratory failure with hypoxia (low oxygen), dyskinesia of esophagus, abscess of lung without pneumonia ( an infection in your lungs that causes them to fill with fluid or pus, making it difficult to breathe.) of the lungs that causes inflammation of the, acute respiratory failure with hypercapnia (have too much carbon dioxide [CO2] in your blood, pulmonary fibrosis (a lung disease that causes deep lung tissue to became thick and scarred, making it hard to breathe and get oxygen into the blood).Record review of Resident #78's admission MDS, dated [DATE], indicated a BIMS score 08, which indicated moderate cognitive impairment. Resident # 78 was totally dependent on two or more staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. He required 1 to 2 people for assistance with activities of daily living. Resident #78 was also marked in section K0510 Nutritional. Approach as B. Feeding Tube while a resident. Record review of Resident #78's Physician's Orders, dated 09/11/25, reflected the following orders: Had NPO (Nothing per oral) only GT: Bolus give 1 can Isosource 1.5 five times a day. Check for residual every shift if > 150cc's, stop feeding and notify MD every shift. Flush GT with 30 ml water before and after administration of meds, flush with 10 cc between each medication every shift.Record review of Resident #78's physician's summary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 5 of 13 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 11/21/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete orders and MAR with start date of 09/11/25 for the following medications:1. Sucralfate Oral Suspension 1GM/10ml. Give 10 ml via Peg-Tube before meals at bedtime for gastric ulcer (use to treat and prevent duodenal ulcers and other conditions as determined by your doctor).During an observation of peg-tube medication administration on 09/23/2023 at 11:09 AM, LVN K did not verify placement of Resident #78's peg tube. LVN K did not palpate Resident #78's stomach. LVN K crushed Sucralfate 1 gm in pill crusher and poured it in a medicine cup then tried to dissolve Sucralfate with 5 cc of water, then used the syringe tip to mix it, it would not dissolved she then removed the syringe plunger, did not check the residual, the resident said he was too full of breakfast. LVN K said she was holding Resident #78's bolus feeding, LVN K then poured 20cc of water in the syringe, there was a milky substance flowing back from the stomach into the tubing and was not going down despite LVN K milking the peg-tube. LVN K poured the residual with water in a cup, and she removed the syringe and went to the restroom to rinse the syringe, she placed the plunger in the syringe, then checked the residual, it was about 10cc, she did not return it to the stomach she poured it in a cup. LVN K then tried to administer Sucralfate 1gm, it was not going down the peg tube, she picked up the cups and threw the cups in the trash. The State Surveyor picked up the Sucralfate medicine cup from the trash and LVN K stated the medication (Sucralfate) was not given in totality because she was not able to dissolve it and the family member did not want the medication changed. The DON was shown the crushed medication (Sucralfate)in the medicine cup. During an interview with LVN K on 09/23/25 at 12:45 PM, regarding not checking the peg tube placement for Resident #78 GT before medication administration and LVN K not checking for placement could cause aspiration pneumonia, bloating and being too full. Further interview with LVN K on 09/23/25 at 12:45 PM, LVN K said she would be more careful and would double-check after pouring medications, LVN K said he had medication training upon hire by DON. Record review of enteral feed order schedule for [DATE], reflected every shift check tube for proper placement by visual inspection of aspirated stomach content prior to instilling medication, initiating a feeding or when there is an interruption of feeding, or at least every shift for continuous feeding. Enteral feed order schedule for [DATE], had every shift flush with 30-60 ml water before and after medication, before initiating feeding or when there was an interruption of feeding to maintain tube patency.During an interview on 09/25/25 at 12:50 PM, the DON reported a feeding tube should be verified with a stethoscope and a staff member should listen to gurgling. The DON reported if you do not verify if a feeding tube was in the right place, then a resident could receive a feeding or medication that could result in infection, bloating, or discomfort. The DON stated the two policies provided were what the facility had for feeding tube administration and they had a policy specific on verifying feeding tube placement. Record review of the facility provided policy titled Flushing a Feeding Tube, revised 2021, reflected the following . Policy Explanation and compliance Guidelines .9. Prior to flushing the feeding tube, the administration of medication or providing tube feedings, the nurse verifies the proper placement by noting the length of the tubing or performing a measure of the PH of gastric secretions, if performed in the facility. 10. After tube placement has been verified, flush the tube utilizing the 60 ml, catheter tip syringe with the prescribed amount of water every four (4) hours, before and after feedings and medications or as directed by the physician. Allow medications to flow down the medication syringe. Event ID: Facility ID: 676273 If continuation sheet Page 6 of 13 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 11/21/2025 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete 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 reviewed for food procurement in 1 of 1 kitchen to demonstrate the prevalence of the noncompliance in that: -The facility failed to ensure 10 pounds of raw fish was stored at proper temperature. -The facility failed to ensure scoops were not stored in food bins. -The facility failed to ensure gallons of milk were not stored on a rack 4 1/2 inches off the floor. These failures could place residents at risk of food borne illnesses and diseases. Observation and interview on 9/09/25 between 8:30 am and 8:40 am with the Dietary Manager revealed the following: -10 pounds of raw fish was inappropriately being held on a pan being thawed at room temperature, evidenced by taking the temperature revealed the internal temperatures of 64 degrees Fahrenheit. -Scoops with handles submerged in the sugar bin and flour bin. -4 gallons of milk were on a rack 4 1/2 inches off the floor in the walk-in refrigerator. Interview with the Dietary Manager on 09/09/25 at 8:40 AM, she stated food held with danger zone temperature could place the residents who ate the food at risk of food borne illness and disease. She also stated frozen food should not be thawed at room temperature. Scoops in the food bins could cause cross- contamination and the staff should be storing the scoops container not touching food. Food had to be stored 6 inches off the floor. She stated that she was responsible for training staff on proper storage/temperature. Record review of facility's Food and Nutrition Services Policy and Procedure Manual dated revision date January 2012 read in part Cold foods shall be maintained at temperatures of 40 degrees Fahrenheit or below. Hot foods or potentially hazardous food shall have a temperature of 140 degrees Fahrenheit or above. Food service scoops are not permitted to be stored inside dry storage bins, ingredient containers or product bags. This practice poses a risk of contamination from handles or hands coming into contact with food product. All foods must be kept on shelves at least 6 inches off the floor to prevent contamination and facilitate cleaning. Record review of FDA Food Code 2022 read in part .3-501.11 Frozen foods shall be maintained frozen. 3-501.12 Time/Temperature Control for safety food shall be held under refrigeration that maintain the food temperature at 41 degrees Fahrenheit or less or at any temperature if the food remains frozen. Event ID: Facility ID: 676273 If continuation sheet Page 7 of 13 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 11/21/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records on each resident were maintained that were complete and accurately documented for 1 of 6 residents (Resident #144) reviewed for accurate records.-The facility failed to ensure urine output was documented on 9/14/2025 and 9/19/2025 per physician orders for Resident #144.This failure could place residents at risk of changes in condition not being detected and treated in a timely manner. Record review of Resident #144's face sheet, dated 09/25/2025, reflected a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included type 2 diabetes mellitus (high blood sugar), neuromuscular dysfunction of bladder (damage or dysfunction in the nerves or muscles that control bladder function), rheumatoid arthritis (chronic inflammatory disorder affecting small joints in the hands and feet), and extended spectrum beta lactamase resistance (resistance to a bacterium that produces an enzyme making them resistant to certain antibiotics).Record review of Resident #144's physician order summary reflected an order with a start date of 09/12/2025, to record suprapubic catheter output every shift for 6-2, 2-10 and 10-6 shifts. Resident #144 also had orders for cleansing the suprapubic catheter site with NS, pat dry and apply dressing for every shift with a start date of 09/12/2025, nystatin external cream 100000 unit/gm for suprapubic catheter with a start date of 09/24/2025.Record review of Resident #144's Comprehensive MDS, dated [DATE], reflected a BIMS of 15, which indicated she was cognitively intact. Resident #144 required substantial assistance with toileting, showering or bathing, lower body dressing and putting on/taking off footwear. She was coded for having an indwelling catheterRecord review of Resident #144's care plan, captured 09/25/2025, reflected she had an indwelling catheter (a tube inserted into the bladder through the urethra for bladder drainage) suprapubic (below the navel) catheter due to diagnosis of neurogenic bladder with interventions including checking for patency and urinary output every shift. Resident #144 also had a focus area for being on antibiotic therapy due to a urinary tract infection with interventions which included administering medication as ordered and monitoring/communicating sudden changes in condition and or worsening to the MD/NP.Record review of Resident #144's September MAR reflected she did not have recorded output on 09/14/2025 during night shift (10p-6a) and 09/19/2025 during morning shift (6a-2p).Interview with Resident #144 on 09/24/2025 at 11:16 AM, she had no concerns with care at the facility. In a later interview on 09/25/2025 at 3:30pm with Resident #144, she said someone would come two or three times a day and empty her catheter and measured the output. Resident #144 said she had no infection but had a rash near her suprapubic catheter which the wound care nurse was treating and she had orders for zinc oxide and other cream for the skin irritation. Interview with the DON on 09/25/2025 at 11:47 PM, she said aides could empty residents' catheter and report the urine output to the nurse. If the output was not documented, the facility would not know if residents had any output and if interventions were needed. Interview with RN A on 09/25/2025 at 12:21 PM, RN A said they worked 6:00 AM to 6:00 PM. RN A stated they had taken care of Resident #144 on 9/19/2025. RN A said they usually documented output on the electronic medical record, and they wrote the output first but overlooked entering it into the medical record. RN A said they measured the output but did not document. If output was not documented, it could have resulted in a delay in care and things being missed from lack of output. RN A said Resident #144 was doing okay and had no issues with output. Interview with LVN [NAME] 09/25/2025 at 12:27 PM, she said she provided catheter care to Resident #144 who had no complaints about her catheter. LVN G worked 6:00 PM to 6:00 AM and would document Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 8 of 13 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 11/21/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #144's twice since her shift overlapped with Resident #144's orders for output measurement for the two nursing shifts from 2:00 PM-10:00 PM and 10:00 PM-6:00 AM. LVN G said she wrote down the output but did not document the output in Resident #144's medical records and she overlooked it and would go back and do a late entry or progress note. If Resident #144 did not have output, she would have called the doctor to check and continue to monitor. The LVN stated possible negative outcomes of not documenting would be something could go wrong and they would not have it documented such as vitals or UTI . Skills checkoff was requested for LVN A and RN A on 09/25/2025 at 11:50am and was not received as of exit. Record review of the facility's policy on charting and documentation, last revised July 2017, read in part, all services provided to the resident .shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record: c. Treatments or services performed Event ID: Facility ID: 676273 If continuation sheet Page 9 of 13 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 11/21/2025 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #75, Resident #78 and Resident #79) and 1 of 1 Kitchen (Kitchen A) reviewed for infection control. 1.The facility failed to ensure MA E used the required PPE for Resident #75, who was on enhanced barrier precautions, while checking BP on 9/23 /25. 2. The facility failed to ensure LVN K used the required PPE for Resident #78 on 9/23/25. 3. The facility failed to ensure CNA B maintained hand hygiene during incontinent/FC on 9/24/25 for Resident #79. 4. The facility failed to ensure CNA B cleansed around the buttocks for Resident #79 on 9/24/2025. These failures could place residents at risk of cross-contamination, development of infections, and food-borne illnesses and diseases.1.Record review of Resident# 75's reflected the resident was admitted to the facility on [DATE]. Resident #75 had diagnoses which included essential (primary) hypertension (high blood pressure), other hyperlipidemia ( high fat in the blood), chronic kidney disease, stage 3a, other sleep apnea, gastro-esophageal reflux disease without esophagitis (gastric reflux), lymphedema, not elsewhere classified, gout, unspecified, other hyperparathyroidism(Parathyroid glands produce too much parathyroid hormone), inflammatory disorders of other specified male genital organs, bandemia(immature white blood cells called band cells, in their blood), other hydrocele, other specified disorders of the male genital organs, acute cholecystitis, other elevated white blood cell count, epididymitis, left testicular pain, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus without complications ( acute on chronic diastolic (congestive) heart failure, other insomnia.Record review of Resident's #75's admission MDS assessment, dated 08/19/2025, reflected Resident #75's BIMS score was 13, which indicated the cognition was moderately impaired. Resident #75's was incontinent of bowel and continent bladder. Record review of Resident's #75's care plan, dated 8/17/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs. I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff over the next 90 days.Observation on 09/23/25 at 9:52 AM revealed Resident #75 lying in bed. Resident #75 had EBP signage posted outside his door. MA E entered Resident #75's room without donning PPE to check his blood pressure and administer medications. MA E touched Resident #75 and checked his blood pressure using a wrist blood pressure cuff twice. Resident #75 disputed the blood pressure (BP 150/74 P76), MA E went out the resident's room to get a manual blood pressure cuff and rechecked the blood pressure ( BP 114/64 P81) without donning PPE. Interview with the MA E on 9/24/25 at 12:30 PM revealed she forgot to don PPE. MA E said she realized she should have donned PPE to protect the resident and herself for infection. 2. Record review of Resident #78's admission Assessment reflected an [AGE] year-old male who was admitted to the facility on [DATE] and was readmitted on [DATE]. His diagnoses included gastrostomy tube (a small opening into the abdomen and inserted a tube directly into the stomach allowing for food and liquids to be delivered directly into the stomach), dysphagia (difficulty swallowing), diagnoses included essential (primary) hypertension ( high blood pressure) other hyperlipidemia (high lipid/fat in the blood) other specified depressive episodes (persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities that were enjoyed) other specified anemias( healthy red blood cells), obesity (unhealthy amount of extra body fat that can lead to serious health problems like heart disease diabetes), class 2, other disorders of plasma protein metabolism (the process where proteins in the blood plasma are continuously broken down into smaller parts ( Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 10 of 13 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 11/21/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some amino acids) and then rebuilt to form new proteins), not elsewhere classified, narcolepsy without cataplexy(, is a sleep disorder characterized by excessive daytime sleepiness and overwhelming urge to sleep )her pulmonary embolism without acute cor pulmonale (deep vein thrombosis (DVT),tumor emboli, fat emboli from broken bones, air emboli or amniotic fluid emboli) from multiple sclerosis ( a chronic autoimmune disease where the body's immune system mistakenly attacks the protective covering (myelin) of nerve fibers in the brain and spinal cord), other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere, acute respiratory failure with hypoxia (low oxygen), dyskinesia of esophagus, abscess of lung without pneumonia (an infection in your lungs that causes them to fill with fluid or pus, making it difficult to breathe.) of the lungs that causes inflammation of the, acute respiratory failure with hypercapnia( have too much carbon dioxide (CO2) in your blood, pulmonary fibrosis ( a lung disease that causes deep lung tissue to became thick and scarred, making it hard to breathe and get oxygen into the blood).Record review of Resident # 78's admission MDS, dated [DATE], reflected a BIMS score 08, which indicated moderate cognitive impairment. Resident # 78 was totally dependent on two or more staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. He required 1 to 2 people for assistance with activities of daily living. Resident #78 was also marked in section K0510 Nutritional. Approach as B. Feeding Tube while a resident. Record review of Resident #78's Physician's Orders, dated 09/11/25, reflected the following orders: Had NPO (Nothing per oral) only GT: Bolus give 1 can Isosource 1.5 five times a day. Check for residual every shift if > 150cc's, stop feeding and notify MD every shift. Flush GT with 30 ml water before and after administration of meds, flush with 10 cc between each medication every shift.Record review of Resident #78's physician's summary orders and MAR, start date of 09/11/25, reflected the following medications:1. Sucralfate Oral Suspension 1GM/10ml. Give 10 ml via Peg-Tube before meals at bedtime for gastric ulcer (use to treat and prevent duodenal ulcers and other conditions as determined by your doctor).During an observation of peg-tube medication administration on 09/23/2023 at 11:09 AM, revealed Resident #78 had EBP signage posted on his door. LVN K did not don (put on) PPE during medication administration. LVN K did not verify placement of Resident #78's peg tube. LVN K did not palpate Resident #78's stomach. LVN K crushed Sucralfate 1 gm in pill crusher and poured it in a medicine cup then tried to dissolve Sucralfate with 5 cc of water and used the syringe tip to mixed it, it would not dissolved. She removed the syringe plunger, did not check the residual, and the resident said he was too full of breakfast. LVN K said she was holding Resident #78's bolus feeding, LVN K then poured 20cc of water in the syringe, there was a milky substance flowing back form the stomach in to tubing and was not going down despite LVN K milking peg-tube. LVN K then poured the residual with water in a cup, and she removed the syringe and went to restroom to rinse the syringe, she then place the plunger in the syringe, then checked the residual, it was about 10cc she did not return it to the stomach she poured it in a cup. LVN K then tried to administer Sucralfate 1gm, it was not going down the peg tube, she then picked up the cups and threw cups in the trash. Surveyor picked up Sucralfate medicine cup from the trash and LVN K confirmed the medication (Sucralfate) was not given in totality because she was not able to dissolve it and the wife does not want the medication changed. DON was shown crushed medication (Sucralfate)in the medicine cup.During an interview with LVN K on 09/23/25 at 12:45 PM revealed LVN K forgot to don PPE before providing GT medication administration for Resident #78 and she knew not donning PPE could cause infection. LVN K said she would be more careful. In an interview with the DON on 9/24/25 at 12:15 PM, she stated any resident who had wounds, contact isolation, Gastrostomy tube feeding, or Foley catheter was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted outside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 11 of 13 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 11/21/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to the door, which explained what PPE was to be worn and for what task the PPE was to be worn for. She stated any contact with a resident with a catheter required the use of a gown and gloves. She stated the staff received training on the use of Enhanced Barrier Precautions and hand washing. 3/4.Record review of Resident #79's face sheet reflected, the date of admission was 8/27/25 and was readmitted on [DATE]. Resident #79 had diagnoses which included history of generalized anxiety disorder, other specified depressive episodes, obesity, class 1(excess body fat0, other specified hypothyroidism (e03.8), other hyperlipidemia (high lipid/fat in the blood), gastro-esophageal reflux disease without esophagitis, pneumonia due to other specified bacteria, other acute kidney failure, essential (primary) hypertension(high blood pressure), paroxysmal atrial fibrillation (irregular heart beat) obstructive sleep apnea (adult) (pediatric), other specified chronic obstructive pulmonary disease, other insomnia(sleeplessness), other acute osteomyelitis, right ankle and foot, acquired absence of left leg above knee, type 2 diabetes mellitus without complications, chronic systolic (congestive) heart failure, ulcer of anus and rectum, other specified peripheral vascular diseases, acute posthemorrhagic anemia, other hypotension, acute and chronic respiratory failure with hypoxia. Record review of Resident #79's admission MDS assessment, dated 09/16/2025, Section C (Cognitive Patterns) reflected a BIMS score was 14, which indicated no impairment in thinking. Section H (Bladder and Bowel) reflected the resident had an indwelling catheter. Resident #79's functional status reflected she was independent with supervision of staff with bed mobility, transfer and toilet use. Resident#79 had an indwelling Foley catheter. Record review of Resident's #79's care plan, dated 9/14/2025, reflected the following: I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities.I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days. Observation on 09/24/25 at 4:14 PM of incontinent and Foley Catheter care completed by CNA B for Resident #79 revealed Resident #79 had a small pasty BM and CNA B did not open the labia to clean it but did not clean around the buttocks before placing a clean brief and fastened it. CNA B changed gloves 3 three times without washing hands or using hand sanitizer.Interview with CNA B on 9/24/25 at 4:47 PM, she said she was very nervous, she forgot to wash or sanitize her hands or. She said she used wet wipes to clean the groin twice, used the same wipes to clean labia and she did not clean around her buttock. CNA B stated she knew if she didn't clean a resident well it could cause itchiness, skin break down, urinary tract and odors. CNA B further said she usually did not use the same wipes from the groin to clean the labia and she forgot to clean around the buttocks because she was nervous. CNA B said she was in-serviced for incontinent care and skilled check. Interview with the Dietary Manager on 09/09/25 at 8:40 AM, she stated food held with danger zone temperature could place the residents who ate the food at risk of food borne illness and disease. She also stated frozen food should not be thawed at room temperature. Scoops in the food bins could cause cross- contamination and the staff should be storing the scoops container not touching food. Food had to be stored 6 inches off the floor. She stated that she was responsible for training staff on proper storage/temperature. Record review of the facility's policy revised, October 2018, on Enhanced Barrier Precautions, reflected the following: Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO)Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs)refer to infection prevention and control interventions designed to reduce the transmission of multi-drug -resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when:a. A resident with an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676273 If continuation sheet Page 12 of 13 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 11/21/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete infected or colonized with a CDC -targeted, MDRO but does have a wound or indwelling medical device and does not have secretions or excretions that cannot be covered or contained. Record review of CDC guidelines reflected: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Record review of facility's Food and Nutrition Services Policy and Procedure Manual dated revision date January 2012 read in part Cold foods shall be maintained at temperatures of 40 degrees Fahrenheit or below. Hot foods or potentially hazardous food shall have a temperature of 140 degrees Fahrenheit or above. Food service scoops are not permitted to be stored inside dry storage bins, ingredient containers or product bags. This practice poses a risk of contamination from handles or hands coming into contact with food product. All foods must be kept on shelves at least 6 inches off the floor to prevent contamination and facilitate cleaning. Record review of FDA Food Code 2022 read in part .3-501.11 Frozen foods shall be maintained frozen. 3-501.12 Time/Temperature Control for safety food shall be held under refrigeration that maintain the food temperature at 41 degrees Fahrenheit or less or at any temperature if the food remains frozen. Event ID: Facility ID: 676273 If continuation sheet Page 13 of 13