Park Manor Of Westchase

F-F689 2/21/2025

Residents Affected - Few [Facility Name] submits the following Plan of Removal for the alleged failure to ensure residents remain free from accidents and hazards. Note: The nursing home is disputing this citation. What corrective actions have been implemented for the identified residents?

CR#1 is no longer a resident at the time of this plan of removal. No corrective action possible to be taken for CR#1.

How were other residents at risk to be affected by this deficient practice identified?

An audit of all residents who go out on pass within the last 30 days was conducted by the DON on 2/21/25 to ensure that adequate supervision and follow-up was completed for these residents. At the time of the audit, it was noted that there are fifteen residents who routinely go out on pass and no additional supervision or follow-up was required. These residents were verified to be in-house by the DON on 2/21/25. All residents who leave out on pass have the potential to be affected by this alleged deficient practice. All residents who reside in the facility have the right to go out on pass and physician orders are not required to do so.

What does the facility need to change immediately to keep residents safe and ensure it does not happen again?

CR#1 is no longer a resident of the facility as of 2/21/25.

All nursing staff, including CNAs, CMAs and nurses to be in-serviced by DON/Designee on ensuring adequate supervision for residents who leave out on pass and do not return. Additionally, they will be in-serviced on reviewing care plan interventions specific to residents going out on pass. This will be completed by 2/21/25. This includes notifying the administrator, DON and appropriate law enforcement agencies when a resident does not return from being out on pass.

What corrective actions were taken?

1. The following actions were initiated immediately on 2/21/25.

a. On 2/21/25 an audit was completed by DON (Director of Nursing) to ascertain all residents who go out on pass to ensure that their care plans reflected as such. The facility PPS nurse received this list from the DON and will update and revise all resident care plans for those who go out on pass. This will be completed by end of business 2/21/2025.

b. DON and Administrator were educated on 2/21/25 by RVP (Regional [NAME] President of Operations) and CSD (Regional Clinical Services Director) on ensuring adequate supervision and follow up for residents who leave out on pass and do not return.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 0689 c. Newly hired nurses and CNAs to be in-serviced during orientation by DON/Designee on proper procedure for residents who leave out on pass and do not return. Level of Harm - Immediate jeopardy to resident health or d. In-services conducted by DON with nursing staff (CNAs, LVNs, RNs, CMAs) on 2/21/2025 regarding safety residents signing out on pass, reviewing and completion of the resident sign out book, and what to do if they do not return from being out on pass. This would include notifying the Administrator, MD and DON, Residents Affected - Few attempting to contact the resident or RP, searching the premises, and (if resident is unable to be contacted or located) notifying local law enforcement and APS. In-services for all nursing staff to be completed by end Note: The nursing home is of day 2/21/2025. disputing this citation. e. Nursing staff will not be allowed to provide direct care until completion of in-services regarding residents signing out on pass, what to do if residents do not return from being out on pass and following care plan interventions.

f. The facility chief nursing officer reviewed and revised the facility sign-out policy on 2/21/25 to reflect actions needed when a resident does not return from being out on pass.

g. All residents who reside in the facility have the right to go out on pass and physician orders are not required to do so.

h. Facility social worker/designee to audit and correct all active resident charts to verify contact information is up to date for the resident and/or RP. This will be completed by end of day 2/22/25.

How will the system be monitored to ensure compliance?

Nursing staff will review residents sign out book during shift change to identify any residents who are out on pass. If a resident is out on pass greater than eight hours the nursing staff will attempt to contact the resident or RP to ascertain their whereabouts and wellbeing. If unable to reach the resident or RP the nursing staff will notify the DON, MD, and appropriate law enforcement agencies.

DON/Designee will review resident sign out book as part of the morning meeting process to ensure residents and staff are following the facility out on pass policy.

Quality Assurance

An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 2/21/22 with the Medical Director. The Medical Director has reviewed and agrees with this plan.

Monitoring/Observations/Interviews/Record Reviews

Record review of the IJ plan binder:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 0689 -The facility's policy for signing residents out last revised 02/21/2025, read in part, If a resident who has signed out has not returned the same day, then the staff will notify the DON and/or the Administrator. Facility Level of Harm - Immediate staff will attempt to contact the resident/responsible party to determine whether the resident will be returning jeopardy to resident health or to the facility on another date. If the resident or responsible party cannot be reached, then the DON and/or safety the Administrator will initiate an immediate search of the premises. If the resident is not found during this search, then the DON/Administrator will notify local law enforcement/APS. Residents Affected - Few -QAPI Signature page dated 2/21/25 related to CR#1's discharge 1/16/25, Administrator and Medical Note: The nursing home is Director signed along with facility department heads. In-service sheet dated 2/21/2025 regarding team disputing this citation. update on resident safety.

-List of 25 residents highlighted with history of OPT (going out on past) in past 30 days, care plans were updated to include focus area of going out on pass with interventions which included ensuring resident has facility information, ensuring resident signs the out on pass book and notify when resident returns, and staff will verify resident has returned at the end of their shift monitoring if there is any change in condition, initiated 02/21/2025.

-1 to 1 in-service record dated 02/21/2025, topic included residents leaving AMA versus residents out on pass, policy education and review. It read in part, out on pass isn't considered AMA if they don't return. A search must be performed as they are a missing resident. If they want to leave, they must fill out AMA paperwork or if refused to sign must make intentions known otherwise if any resident who leaves will be treated as a missing resident regardless of his or her BIMS. The in-service was completed by the Regional Nurse and Regional VP of Operations

-In-service for nursing staff dated 02/21/2025 from 9:30am to 9:50 am completed by the Administrator which covered the Signing Resident Out policy last revised August 2006. This included sign-in, sign-out procedure, out on pass procedure including residents exiting the building must sign out and if staff recognized a resident had not returned that it be reported to Administrator.

-In-service for nursing staff dated 02/21/2025 at 10:00 am completed by the DON, which covered residents who have gone out in the past and have not returned to the facility is considered missing residents.

-In-service for staff dated 02/21/2025 at 3:40pm and ongoing, which covered checking resident care plans and interventions for those who go out on pass, residents signing out for a pass, nursing documentation being completed, ensuring residents return in stable condition, and reporting a resident not returning within eight hours to management.

-Blank sign out sheet with the following columns: date, resident out on pass (yes or no), shift 6-2, shift 2-10, shift 10-6, and DON/Admin initial.

-Complete census of residents dated 02/21/2025 at 6:49pm with a note, As of 7:30pm 2/21/25, all phone numbers verified and/or corrected and signed by the Administrator. Residents were marked as being their own RP or marked as updated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 0689 -Signing Residents Out policy last revised 02/21/2025 read in part, If a resident who has signed out has not returned the same day, then the staff will notify the DON and/or the Administrator. Facility staff will attempt to Level of Harm - Immediate contact the resident/responsible party to determine whether the resident will be returning to the facility on jeopardy to resident health or another date. If the resident or RP cannot be reached, then the DON and/or the Administrator will initiate an safety immediate search of the premises. If the resident is not found during this search, then the DON/Administrator will notify local law enforcement/APS . Residents Affected - Few

Interview with the DON on 2/22/2025 at 9:20am, she said she did an audit for 23 residents and will update Note: The nursing home is their care plan. disputing this citation.

Interview with RN W on 2/22/2025 at 9:27am, she said she received education on when a resident wanted to go out, she would check their condition and if they're able to make a healthy decision, check their physical condition, check who their RP was, check on transportation, if they needed skilled care during their time on-pass, if they required medication before leaving, check that the resident's contact information is current and let them know to call if they needed the facility's help. She was also educated on checking vital signs, documenting how long they will stay outside, educate the family about conditions to look out for, and see if

the nursing supervisor approved resident's on-pass. If residents did not return according to the provided timeline, she would call their phone number to see if they were okay and tell her supervisor about the situation. Residents have the right to go and the facility should make sure they were safe. She said no residents had left the building on-pass on 2/21/2025 that she was aware of.

Interview with CNA C on 2/22/2025 at 11:36am, she worked 6:00 am to 2:00pm. She was in-serviced on making sure residents told a nurse and signed out before leaving. If staff see residents leaving out the door to call them and verify they followed the protocols. CNA C said staff have to know who residents are leaving with, and if staff have not seen residents return for eight hours, to let a nurse know and they will call the resident to find out how they are.

Interview with CNA B on 2/22/2025 at 11:42am, she worked 6:00 am to 2:00 pm and 2:00pm to 10:00pm.

She received inservices on confirming with residents who were leaving on why they are going out, if they signed out yet and making sure they check with nurses at the facility.

Interview with LVN C on 2/22/2024 at 11:54am, he said he worked 10:00 pm to 6:00 am shift. He was inserviced on making sure residents leaving are competent and finding out who is responsible for them. Nurses are to make sure residents come back, and if they do not staff will initiate a search by calling the resident's RP. If staff are unable to get hold of the person, to notify the DON and Administrator. Leaving is not considered AMA. Nurses document procedures such as going out on pass and documenting the resident's current status, who they are leaving with, how they are before leaving, where they are going and when they are coming back to the facility. Nurses document in the resident's medical records and a physical sheet for residents on each hall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 0689 Interview with the DON on 2/22/2025 at 12:02pm, she in-serviced staff on what to do when residents go out

on pass, including checking the resident's care plan, filling out the sign out form and documenting on-pass Level of Harm - Immediate residents in each nurse's log and to check that before each shift to know which residents are coming back on jeopardy to resident health or that shift. Nurses are to help residents sign out, ask where they're going and document in residents' progress safety notes, make sure phone numbers are working, add vital signs and making sure residents want any medication for pain before leaving. If residents do not appear well, nursing staff are to report to the DON so Residents Affected - Few that the resident and/or family members can be educated to make sure residents stay staff. If residents haven't returned, staff are to call the resident. If they have not returned and if they don't answer, report to Note: The nursing home is management (Unit manager, Administrator, Social Worker, DON). If a resident is unable to be found, the disputing this citation. facility will search the area. If the resident is unable to be found, the facility will call hospitals and police after 24 hours. The DON said that going forward, the facility will visit the resident's address on file if they do not return to the facility after being out on-pass. The DON said that CR#1 was going out every day and never had any problems with health. He did have medical conditions but no severe changes in conditions while at

the facility. The DON said management estimated that CR#1 was able to take care of himself. The DON was notified 01/16/2025 around 9:00 pm through text and she called CR#1 at home and he did not answer. She also called early in the morning the next day. The DON said if residents are not located, they could be on the street in hot or cold weather. The DON will monitor the effectiveness of implemented procedures by reviewing resident sign-out logs for each hall at the end of the day for 30 days. The DON will continue to educate and in-service staff on what to do when residents are leaving a facility and what staff do if they have not returned.

Interview with the AD on 02/22/2025 at 12:15pm, she was in-serviced on resident rights, asking residents where they are going if they leave the building. Staff should also check to make sure residents told their nurse and that the nurses are aware of residents leaving on-pass. If she noticed residents have not returned

she would report it right away to the DON and Administrator. She would also assist with locating residents.

Interview with CNA F on 2/22/2025 at 12:25pm, she said she worked 10:00 pm to 6: 00 am and sometimes helped with 6:00 am to 2:00 pm shift. CNA F said she was in- serviced on asking residents leaving the building where they are going, if they signed out, if they spoke to their nurse, and when they're coming back.

She would notify her nurse if the resident has not returned. She would communicate concerns with the nurse

on residents out on-pass. She had in-services on resident rights in the past.

Interview with the Receptionist on 2/22/2025 at 12:29pm, she said she was in-serviced on stopping residents leaving and making sure they were signed out or direct them to the nurse's station.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 0689 Interview with the Administrator on 2/22/2025 at 12:38pm, she said she was in-serviced by the Regional VP of Operations on 2/21/2025. She conducted in-services for department managers, coordinators and direct Level of Harm - Immediate care staff about the new sign-in and sign-out policy and what needed to be done if residents leave, including jeopardy to resident health or redirecting them to nurse's station to sign in the log book, educating nurses on confirming a resident's RP, safety having contact information of the resident or family member, making sure residents return and reporting immediately to her or the DON if residents do not return. The Administrator said staff are to conduct Residents Affected - Few follow-ups by calling the resident's RP and confirming an expected time to come back. If staff cannot get a response, they are to search the facility and premises and get law enforcement involved and calling the Note: The nursing home is location resident said they were going. The Administrator said CR#1 signed out and the follow-up did not disputing this citation. take place at the time. She was informed on 01/16/2025 late in the evening. She said CR#1 was not considered missing due to him frequently leaving the facility on-pass, but if a resident was noted to be missing and had not come back when they said they would, the facility would conduct a search and notify law enforcement. The Administrator said based off the conditions of CR#1 at the time and his habits, the facility felt he left the facility of his own choosing and was not in immediate danger. She discussed CR#1 with

the DON, notified the doctor who gave us the discharge directives which was the AMA paperwork. The Administrator will monitor the implemented procedures with continuing to follow the sign-in and sign-out log and shift reports which they were already doing. She will also monitor the new separate logs for each hall in which nurses will review before starting the shift. Staff are expected to send a message to the DON and the Administrator for the time being when residents go out so they can make sure residents return. The monitoring period will be 90 days, and binders are to be reviewed at morning meetings, with the weekend RN supervisor monitoring to ensure protocols are being done.

Interview with the BOM on 2/22/2025 at 12:50pm, she said she was in-serviced on letting the DON and Administrator know when she sees a resident leaving the facility. She said she will call the resident o [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36918

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure residents who were 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 #31) reviewed for incontinent care.

The facility failed to ensure CNA C did not place foley bag on Resident #31's bed during foley care.

The facility failed to ensure CNA C properly cleaned Resident #31during incontinent care.

This failure could place residents at risk for pain, infection, injury, and hospitalization .

Findings included:

Record review of Resident #31's sheet dated 02/19/25 revealed a [AGE] year-old female was initially admitted to the facility on ,d+[DATE REDACTED]//21 and readmitted on [DATE REDACTED]. Resident #31 had diagnoses included: chronic kidney disease (a condition where kidneys are damaged and cannot filter blood properly), diabetes mellitus (body do not produce enough insulin or use it properly) and heart failure (heart cannot pump enough blood to meet the body's needs).

Record review of Resident #31's Quarterly MDS assessment dated [DATE REDACTED] revealed Resident BIMS was 09 which indicated moderately impaired cognition. Resident #31 required extensive assistance with ADL with one staff assistant. Further review revealed the resident was incontinent of bowel and she had an indwelling catheter.

Record review of Resident # 31's care plan initiated on 12/20/23 revealed Resident #31 had Indwelling Catheter dx: neurogenic bladder Interventions: Position catheter bag and tubing below the level of the bladder. Check for incontinence during rounds, wash, rinse, dry perineum and change clothing PRN after incontinence episodes.

Record review of Resident #31's order summary report for February 2025 read in part . FC: Foley catheter 16 FR 10 cc bulb to bedside drainage, diagnosis: neurogenic bladder ordered date 02/27/24 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 During an observation on 01/18/25 at 9:54 a.m., CNA C placed Resident #31's Foley bag on the bed while

she provided incontinence and Foley care for Resident #31. The IP was in Resident #31's room, and she Level of Harm - Minimal harm or observed the care with the surveyor. Resident #31's foley bag was on the bed from 9:54 a.m. to 10:10 a.m. potential for actual harm until the IP told CNA C to put the foley bag down below Resident # 31's bladder. CNA C wiped Resident #31's peri area during the incontinent and foley care. Still, she did not separate the labia (fleshy folds of skin Residents Affected - Few that make up the external female genitalia), and she also did not separate the buttocks when she cleaned

the bowel movement. When CNA C wiped the foley catheter French towards the body, instead of wiping away from the body, she did not anchor the foley French close to the insertion site to prevent the foley French from pulling when she cleaned the catheter French. The IP asked CNA C if she had finished cleaning Resident #31 and she said yes. Then the IP asked CNA C to separate Resident #31 buttocks and clean it again. When CNA C separated Resident #31's buttocks, she cleaned in between the buttocks and the anal three times, and there was bowel movement on the wipes. Then CNA C separated Resident #31's labia, revealing the area was red. When CNA C wiped the inside of the labia area, Resident #31 shouted, OUCH, and there was bowel movement and a tinge of red streaks when she wiped Resident #31 three more times.

During an interview on 02/18/25 at 1:03 p.m., CNA C said she left the Foley bag on top of the bed when she provided Foley and incontinent care for Resident #31 until the IP told her to place the bag below Resident #31 bladder, and she hung the foley bag on the rail of the bed. CNA C said she had in-service on Foley care and was told to have the Foley bag below the bladder so the urine would flow down. CAN C said she placed

the bag on the bed, which was on the same level as the bladder and the urine would flow back and could cause infection (UTI) for Resident #31.

During an interview on 02/18/25 at 1:03 p.m., CNA C said she should have separated Resident #31 labia and buttocks to clean Resident #31 properly. CNA C said when the IP told her to clean Resident #31, she did

it three more times, and there was a bowel movement on the wipes. She said if she did not clean Resident #31 well, she could have all kinds of infections. CNA C did not state what types of infection. CNA C said she had an in-service on Foley care and incontinent care, and the trainer said to use soap and water and clean

the area until it is clean.

During an interview on 02/19/25 at 8:13 a.m., the IP Said CNA C should not have placed the foley bag on the bed because the urine would backflow into Resident #31, and it could cause infection such as UTI. The IP said the nursing staff was responsible for ensuring the Foley bag was placed below the bladder. The IP said CNA C should have separated the labia and cleaned the area and the buttocks properly. The IP said when

she asked CNA C to clean the buttocks and peri area after she said she was done cleaning Resident #31.

The IP said CNA C cleaned out bowel movement residue both from the peri area and the rectum three more times, and the wipes had bowel movements.

During an interview on 02/19/25 at 10::08 a.m., LVN S said CNA C should place Resident #31 foley bag at

the foot of the bed or on the rail below the resident's bladder for the urine to flow through gravity. LVN S said

the urine would flow back into Resident #31 bladder because CNA C placed the Foley on the bed at the same level as the bladder, and it could cause infection (UTI).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 During an interview on 02/19/25 at 10:36 a.m., the DON said she expected CNA C to follow facility protocol

on Foley care, and the IP would train CNA C before she started working on the floor, and she was trained. Level of Harm - Minimal harm or The DON said the Foley bag should not be above or at the same bladder level. The DON said the IP potential for actual harm educated the aides not to put the Foley bag on the bed because the urine would flow back to the resident, and it would cause UTI. The DON said the staffing coordinator, the IP, and herself monitored the nurse Residents Affected - Few during rounding, and the nurse monitored the aides. The DON said if CNA C did not separate the labia area and if she did not appropriately clean, Resident #31 could get an infection. The DON said CNA C should anchor the tubing clean in a circular motion and wipe away from the resident, not towards the resident, to prevent UTI.

During an interview on 02/19/25 at 3:03 p.m., the Administrator said CNA C should not have placed the foley bag on the same level of the bladder because the urine would flow back into Resident #31 bladder and Resident #31 could have an infection. The Administrator said CNA C should clean Resident #31's peri and rectum areas properly to prevent infection and skin breakdown.

Record review of the facility's policy on Peri Care dated 2001 MED - PASS, Inc. Revised October 2010 read

in part . the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition .steps in the procedure #9b(1) separate labia and wash area downward from front to back . note: if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36918

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 of 3 residents reviewed with gastrostomy tubes. (g-tubes) (Resident #76)

CNA F did not inform the nurse to turn off Resident #76's gastrostomy tube feeding prior to providing care.

CNA F lowered the head of Resident #76's bed to a flat position for incontinent care while the g-tube feeding continued to infuse.

This failure could place residents with g- tubes at risk for complications, aspiration, and pneumonia.

Findings included:

Record review of Resident #76's sheet dated 02/19/25 revealed a [AGE] year-old female was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident #76 had diagnoses included: PEG tube (a feeding tube placed into the stomach), diabetes mellitus (body do not produce enough insulin or use

it properly) and hypertension (blood vessels have persistently raised pressure).

Record review of Resident #76's Quarterly MDS assessment dated ,d+[DATE REDACTED] revealed Resident BIMS was 06 which indicated severely impaired cognition. Resident #76 required extensive assistance with ADL with one staff assistant. Further review revealed the resident PEG tube.

Record review of Resident # 76's care plan initiated on 06/24/24revealed Resident #76 had requires tube feeding related to dysphagia. Intervention: keep HOB elevated 45 degrees during and thirty minutes after tube feed. Observe side effects of feed intolerance/ aspiration: diarrhea, N/V, increased cough,

Record review of Resident #76's physician for February 2025 read in part . GT: head of bed elevated at 30 to 45 degrees except to allow for ADL care ordered date 06/07/24 . GT: flush GT with H2O at 38 ML/HR for 22 hours VIA pump QD . GT: give Jevity 1.5 at 60CC/HR for 22 hours ordered date 01/08/25 .

During an observation on 02/19/25 at 9:30 a.m., it was revealed Resident #76 was lying on the bed with the head of the bed flat while G tube feeding was infusing. CNA F continued to provide incontinent care, and when he finished giving care, he still left Resident #76 head of flat.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 During an observation and interview on 02/19/25 at 9:49 a.m., LVN S said he observed Resident #76's head of the bed was flat, and the feeding was running. LVN S said Resident # 76 feeding should not be running Level of Harm - Minimal harm or while CNA F was providing incontinent care. LVN S said the head of the bed should not be flat because of potential for actual harm aspiration, and if Resident #76 starts to aspirate and the resident was not found on time, that could be fatal for Resident#76. LVN S said CNA F should have told the nurse he was about to provide incontinent care so Residents Affected - Few the nurse would turn off the G tube. After CNA F had provided the incontinent care for Resident #76, CNA F would tell the nurse, and the nurse would come and turn the feeding pulp on and make sure Resident #76's head of the bed was not flat. LVN S said the head of the bed should be between 35 and 40 degrees. LVN S said the charge nurse monitored the aides, but he did not know how the aides missed calling him. LVN S said the unit managers monitored the nurses during rounding.

During an interview on 02/19/25 at 11:01 a.m., the DON said Resident #76's feeding should be placed on hold by the nurse while CNA F provided care for the resident. The DON said the feeding should be on hold to prevent Resident #76 from vomiting and abdominal pain. The DON said the facility has a standing order and protocol for residents on G tube, which is that the head of the bed should be elevated while the feeding is running and pulsed during care so the head of the bed can be lowered. The DON said CNA F was trained to tell the nurse to come to turn off the plump and to turn it back on aftercare.

During an interview on 02/19/25 at 1:02 p.m., CNA F said the feeding was not stopped when he provided care for Resident #76 because he forgot about it. CNA F said the head of the bed was down, and he did not know what could happen to Resident #76 with the head of the bed down while the feeding was going on. CNA F said he had training on how to work with a resident with a G tube, and he did not remember what could happen to Resident #76, and the nurse monitored the aides during rounding.

Record review of the facility undated training for staff on handling patients with PEG tubes during ADL care read in part .important steps before starting ADL care: 1. if a CAN is caring for a resident with a peg tube,

they must call the nurse to pause the feeding before starting activities of daily living. This is particularly important if the care involves position changes, turning the patient, . that could increase the risk of aspiration. Reasons to pause feeding during ADL care .1. aspiration risk . repositioning the patient while they are being fed can lead to reflux and increase the risk of aspiration . resume feeding only once the patient is returned to

a safe, upright position .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36918 potential for actual harm Based on observation, interview, and record review the facility failed to ensure that a resident who needed Residents Affected - Few respiratory care and services, including oxygen administration was provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #81) reviewed for respiratory therapy in that:

The facility failed to ensure Resident #81's oxygen was set according to physician orders.

This failure could place residents at risk of respiratory distress.

The findings were:

Record review of Resident #81's face sheet dated 02/19/25 revealed a [AGE] years- old female was admitted to the facility on [DATE REDACTED]. Resident #66 had diagnoses included: cerebral infraction (brain injury occurs when blood flow to the brain is blocked), hypertension (when blood against the walls of arteries is consistently too high), heart failure (heart cannot pump enough blood to meet the body's needs) and aphasia(language disorder that affects communication).

Record review of Resident #81 admission MDS assessment dated [DATE REDACTED] revealed Resident #81 had a BIMS of 00 out of 15 indicated severely impaired cognition. further review revealed Resident #81 was on oxygen therapy.

Record review of Resident #81 care plan dated 02/03//25 revealed Resident#81 had potential for respiratory distress related to CVA, HX of TIA, CHF on oxygen therapy. Intervention: give nebulizer treatment and oxygen therapy as ordered. oxygen settings: 02 via nasal cannula @ 3L continuously.

Record review of Resident#81's physician's order dated February 2025 read in part . O2: O2 at 3L/minute via nc continuously every shift stated 01/31//25 .

During an observation on 02/18/25 at 10:31 a.m., revealed Resident #81 oxygen concentrator was set on 3. 5L

During an observation on 02/18/25 at 10:32 a.m., CNA C said the setting on the oxygen concentrator was between 3 and 4 L.

During an observation and interview on 02/18/25 at 10:37 a.m., LVN S said the setting on the oxygen was 3. 5 L. LVN S said he did not know how many liters of oxygen Resident #81 should be on. LVN S Resident #81 was moved to this hall yesterday (02/17/24).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 0695 During an interview on 02/19/25 at 7:56 a.m., the IP said if the doctor's order said 2 to 3 L, Resident #81's should be set according to the order. The IP said it should not be above the order because Resident #81 Level of Harm - Minimal harm or could have COPD, and it would not be safe for the resident because it could do more harm than good. The potential for actual harm IP said the charge nurses are responsible for making sure the setting on the concentrator was set according to the order. The IP said the nurse managers also check the sets on the oxygen concentrator when they Residents Affected - Few make rounds. The IP said the nurse managers monitored the nurses, and the nurses had skills checks off, and it included oxygen administration.

During an interview on 02/19/25 at 10::03 a.m., LVN S said Resident #81 setting on the oxygen concentrator should be set at what the physician ordered. LVN S said he did not get a report from the outgoing nurse and did not know why the concentrator was set at 3. 5 L. LVN S said the resident would have some adverse effects, but he could not verbalize what effect.

During an interview on 02/19/25 at 10:27 a.m., the DON said LVN S or any other nurse did not tell her Resident #81 was having any respiratory issues, and they increased the O2 setting on the concentrator. The DON said the facility follows the physician's order. The DON said if Resident #81 was given more oxygen than ordered, the CO2 would increase, and Resident #81 would be more confused than usual. The DON said the charge nurse on the floor was responsible for monitoring the oxygen setting. The DON said the unit managers and the DON monitor the nurses during rounding. She said the nurses had a skills check-off, which included oxygen administration before working with residents with oxygen.

Oxygen policy as requested from the administrator and DON on 02/19/25 at 4:29 p.m., through email and the policy was not provided upon exit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 16352 Residents Affected - Some Based on observation and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 3 (shared medication cart between Hall 100 and 400, 200 and 300 ) of 6 medication carts reviewed for medication storage.

- The facility failed to ensure the 200,300, shared 100 and 400 hall medication carts did not contain eyedrops, ointment, and nasal spray that were opened but not labeled with the resident's name and not dated.

This failure could place residents at risk of adverse medication reactions and infections.

Findings Include:

During observation on 02/19/25 at 2:50 PM, the following medications were found in the medication carts for 200 hall with LVN AA:

Serevent Diskus (Salmeterol Xinafoate inhalation powder) open and not dated

Trelegy Ellipta 200 mcg inhalation power open and not dated

Nystatin & Triamcinolone Acetonide 60gms open and not dated

Diclofenac Sodium topical gel 1% (NSAID) arthritis pain reliever open and not dated

Interview with LVN AA on 2/19/25 at 2:50 PM, LVN AA asked the surveyor if she could date the medication because she was not sure when it was open. She said the reason for dating the medications was for the medication not to be used after 30 days for it to be effective.

During observation on 02/19/25 at 3:05 PM, the following medications were found in the medication carts for 300 hall with LVN BB:

Refresh Optive Mega -3 with 4 vials open and not dated

Refresh Optive Mega -3 with 2 vials open and not dated

Refresh Optive Mega -3 with 2 vials open and not dated

Interview with LVN BB on 2/19/25 at 3:05 PM, LVN BB said she checks the medication cart for 300 halls daily for expired medications. LVN BB said eyedrops when medication open should be dated, to help the nurses know when to discard it after 30 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 During observation on 02/19/25 at 3:30 PM, the following medications were found in the medication carts shared between 100 and 400 hall with MA A. Level of Harm - Minimal harm or potential for actual harm 1. Fluticasone USP 50 mcg nasal spray open and not dated

Residents Affected - Some 2. Fluticasone USP 50 mcg nasal spray open and not dated

3. Fluticasone USP 50 mcg nasal spray open and not dated

4. Fluticasone USP 50 mcg nasal spray open and not dated

5. Fluticasone USP 50 mcg nasal spray open and not dated

6. Fluticasone USP 50 mcg nasal spray open and not dated

7 Fluticasone USP 50 mcg nasal spray open and not dated

8. Fluticasone USP 50 mcg nasal spray open and not dated

9. Fluticasone USP 50 mcg nasal spray open and not dated

10. Allergy Nasal Spray open and not dated

11. Refresh Plus lubricant eye-30 single vial

Interview with MA A on 02/19/25 at 3:30PM regarding medication not dated she said the resident gets it in

the morning and not dating could cause harm to the resident because it will not be effective and she would showing the medication to the DON.

In an interview with DON 2/19/25 at 4:00 PM, she said was not sure if they were supposed to labeled above medications when opened and the pharmacist was in the facility on 2/18/25 and said everything was fine. DON said they were going to look into their policy.

Record review of the facility policy of storage of medications revised April 2007 :Policy Statement : The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation did not address the labelling and dating of medications when opened.

According to the United [NAME] health trust, recommendations were that drops and ointments are used within one month (https://www.ghc.nhs.uk/wp-content/uploads/CHST-Expiry-Dates-of-Medication.pdf).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 16352 potential for actual harm Based on observation, interview and record review the facility failed to establish and maintain an infection Residents Affected - Some 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 4 residents (Resident #31, Residents #41 and Resident #76) reviewed for infection control practices.

- The facility failed to ensure CNA C followed proper infection control and hand hygiene for Resident #31

during Foley and incontinent care.

- CNA AA did not utilize appropriate hand hygiene during Foley catheter care for Resident #41

- CNA AA did not utilize appropriate hand hygiene during incontinent for Resident #41

- The facility failed to ensure CNA F Donned proper PPE while providing incontinent care for Resident # 76 who was in enhanced barrier precaution isolation.

These failures could place residents at risk of infection or a decline in health.

The findings include:

Resident #31

Record review of Resident #31's sheet dated 02/19/25 revealed a [AGE] year-old female was initially admitted to the facility on ,d+[DATE REDACTED]//21 and readmitted on [DATE REDACTED]. Resident #31 had diagnoses included: chronic kidney disease (a condition where kidneys are damaged and cannot filter blood properly), diabetes mellitus (body do not produce enough insulin or use it properly) and heart failure (heart cannot pump enough blood to meet the body's needs).

Record review of Resident #31's Quarterly MDS assessment dated [DATE REDACTED] revealed Resident BIMS was 09 which indicated moderately impaired cognition. Resident #31 required extensive assistance with ADL(activity of daily living) with one staff assistant. Further review revealed the resident was incontinent of bowel and she had an indwelling catheter.

Record review of Resident # 31's care plan initiated on 12/20/23 revealed Resident #31 had Indwelling Catheter dx: neurogenic bladder(lack of bladder control) Interventions: Position catheter bag and tubing below the level of the bladder. Check for incontinence during rounds, wash, rinse, dry perineum(patch od sensitive skin between virginal opening and anus) and change clothing PRN after incontinence episodes.

Record review of Resident #31's order summary report for February 2025 read in part . FC: Foley catheter 16 FR 10 cc bulb to bedside drainage, diagnosis: neurogenic bladder ordered date 02/27/24 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 During an observation on 01/18/25 at 9:54 a.m., when CNA C was providing Foley and incontinent care for Resident #31, CNA C placed a clear plastic bag on the clean field, and it was touching the clean incontinent Level of Harm - Minimal harm or brief and wipe packet. CNA C placed the used wipes, which had bowel movements, and used incontinent potential for actual harm briefs, which also had bowel movements, in the clear plastic bag. CNA C changed dirty gloves with bowel movements three times without sanitizing or washing her hands. When CNA C was about to DON(putting on Residents Affected - Some gloves)the fourth gloves, the IP told her to go and wash her hands.

During an interview on 02/18/25 at 12:54 p.m., CNA C said she should not have placed the thrash bag on the clean field and had the soil linen and wipes in the bag because of cross-contamination. CNA C said she forgot to wash her hands after she changed gloves three times, which had a bowel movement. CNA C said

the IP told her to wash her hands when she was about to [NAME] the fourth glove without washing or sanitizing her hands. CNA C said it was an infection control issue because she did not wash her hands. CNA C said she had been in service on infection control and was educated to wash or sanitize her hands when

she changed gloves to prevent cross-contamination. She stated the nurses monitored the aides when the nurses made rounds.

During an interview on 02/19/25 at 8:20 a.m., the IP said CNA C should not have placed a trash bag on a clean field on a bedside table with clean supplies for incontinent care to prevent cross-contamination. The IP said CNA C changed dirty gloves three times without washing or sanitizing her hands, and on the fourth change, she told CNA C to go and wash her hands because of cross-contamination.

During an interview on 02/19/25 at 10:49 a.m., the DON said CNA C should sanitize her hands after removing dirty gloves. The DON said CNA C should have sanitized her hands when she changed the used gloves to prevent cross-contamination. The DON said CNA C should not place her trash on the clean field to avoid cross-contamination. The DON said the IP had in-service on hand washing with the nursing staff, the nurses monitored the aides during rounding, and the nurse managers monitored the nurses.

During an Interview on 02/19/25 at 3:04 p.m., the Administrator said that CNA C placed the dirty line bag on

the clean field and did not wash her hands when she changed the dirty gloves during foley and incontinent care was an infection control issue, which was cross-contamination.

Resident #41

Record review of Resident #41's face sheet, dated 02/19/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE REDACTED]. Resident #41 had diagnoses which included: metabolic encephalopathy (

a brain condition that occurs due to an imbalance of chemicals in the blood) acute cystitis with hematuria (a bladder infection that causes blood in the urine), essential (primary) hypertension, (high blood pressure) hyperlipidemia( high levels of fat in the blood), Parkinson's disease with dyskinesia movements(a condition where a person with Parkinson's disease experiences involuntary muscle movement) and Foley catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine).

Record review of Resident's #41 admission MDS assessment, dated 01/18/2025, reflected the BIMS score was 10, which indicated the resident's cognition was moderately impaired. Resident #41 had an indwelling catheter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 Record review of Resident #41's care plan, date 01/30/25, reflected the resident was at risk of urinary tract infections. Interventions included for caregiver teaching to include good hygiene practices, wipe, and cleanse Level of Harm - Minimal harm or from front to back and clean peri area well after bowel movement in order to help prevent bacteria in urinary potential for actual harm tract.

Residents Affected - Some Record review of physician's order dated 1/14/25 Order Summary: FC: Foley Catheter 16FR 10cc bulb to bedside drainage, Foley catheter care Q shift and PRN : Diagnosis: urinary obstruction.

Observation on 02/19/25 8:49 AM Resident#41 was lying in bed, HOB at 35-degree, resident was lying on

the right side with F/C hanging on the left of the bed frame not secured. Incontinent care performed by CNA AA and CNA BB assisting. CNA AA entered Resident #41's room with enhanced precaution and washed hands (don gown and gloves). CNA AA cranked resident #41's bed to the position of comfort, without changing the gloves, she used the same gloved hands removed resident's cover sheet, then positioned resident on his back, open up Resident #41's brief, the indwelling catheter tubing was under resident draw sheet with Resident #41, lying on it in the bed.

Resident #41 had 200 yellow urine in the drainage bag and large BM. Using the wet wipes CNA AA cleaned

the groin several times and cleaned F/C straight down twice not in a circular motion, then repositioned to his right side, using the same gloves got the wipes and cleaned the buttock with large, bowel movement several times. C.NA AA then changed gloves without washing hands or using hand sanitizers, before donning a clean gloves, she then touched resident #41's call light to call for the treatment nurse for the soiled dressing to the sacral area. At 2/19/25 at 9:06 AM treatment LVN QQ came in to change the treatment.

Interview with CNA BB on 2/19/25 at 9:25AM, about the F/C and incontinent care, she said CNA AA did not washed her hands after changing gloves, and she did not cleaned the F/C in a circular motion and F/C was not secured and it should be positioned on the same side Resident #41 was lying to avoid pulling. C.NA BB said she had in-services for incontinent and F/C training last month.

Interview with CNA AA on 2/19/25 at 9:27 AM, about the incontinent and Foley catheter care, she thinks she did not do a good job, she said she was very nervous, and she forgot to changed her gloves and not changing gloves can cause cross contamination and infection. CNA AA had been working in the facility for 10 months and she had training for 6 weeks for incontinent and indwelling catheter care.

Interview with the LVN QQ on 2/20/25 at 9:52 AM, LVN QQ been here a year in December 2024, 6-2p M-F, on

200 Hall which he worked has 2 residents with Foley catheter. CNAs and I monitor the Foley catheter. LVN QQ said he

check the catheter when entered the facility, he said he checked on Resident #41l yesterday, I don't recall checking on the catheter today during multiple visits. LVN QQ said he was checking to make sure its flowing, making sure any sediment, blood in urine or if it's kinked up. It should have a stat lock to hold it. I don't know what it's called, could be safe lock. We lock it to hold it in place, stable, to prevent yanking, stretching, and causing trauma to the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 If the urine isn't flowing and can be blocked. LVN QQ said he check it a couple of times a day, in the morning and see what the amount residents have in their bag and empty it. I will check it later in the afternoon. When Level of Harm - Minimal harm or I go in and out I do check on the bag. LVN QQ said he had in-services on catheter care, he doesn't potential for actual harm remember when.

Residents Affected - Some Resident #41 does not have a history of UTI. Lack of Foley care can cause obstruction.

In the continued interview, he was asked who was responsible for checking indwelling catheter was secured and monitoring it. LVN QQ said he was responsible and he checks it every so often and did not say when last the indwelling catheter was checked.

During an interview on 2/20/25 at 5:25 PM, the DON revealed staff should be utilizing appropriate hand hygiene practices to prevent an infection. The DON revealed it was necessary to sanitize or wash the hands between glove changes. The DON stated she would conduct in-services now on peri care and infection control.

Resident #76

Record review of Resident #76's sheet dated 02/19/25 revealed a [AGE] year-old female was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident #76 had diagnoses included: PEG tube (a feeding tube placed into the stomach), diabetes mellitus (body do not produce enough insulin or use

it properly) and hypertension (blood vessels have persistently raised pressure).

Record review of Resident #76's Quarterly MDS assessment dated ,d+[DATE REDACTED] revealed Resident BIMS was 06 which indicated severely impaired cognition. Resident #76 required extensive assistance with ADL with one staff assistant. Further review revealed the resident had a PEG tube.

Record review of Resident # 76's care plan initiated on 06/24/24revealed Resident #76 had requires tube feeding related to dysphagia. Intervention: keep HOB elevated 45 degrees during and thirty minutes after tube feed. Observe side effects of feed intolerance/ aspiration: diarrhea, N/V, increased cough,

Record review of Resident #76's physician for February 2025 read in part . GT: head of bed elevated at 30 to 45 degrees except to allow for ADL care ordered date 06/07/24 . GT: flush GT with H2O at 38 ML/HR for 22 hours VIA pump QD . GT: give Jevity 1.5 at 60CC/HR for 22 hours ordered date 01/08/25 .

During an observation on 02/19/25 at 9:54 a.m. revealed CNA F was providing incontinent care for Resident #76, who was in the EBP room, and he did not wear a protective gown.

During an interview on 02/19/25 at 9:57 a.m., LVN S said CNA F should have worn the protective gown while

he provided incontinent care for Resident #76 because she was on EBP. LVN S said he observed CNA F providing incontinent care without a gown, and that was when he gave CNA F a gown and told him to stop and don the gown. LVN S said the rationale for wearing a gown was to prevent cross-contamination because Resident #76 had a G tube and wound. LVN S said the nurse monitors the aides while the nurse managers monitor the nurses. LVN S said he had in service on infection control, including PPE.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 676059 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676059 B. Wing 02/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

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 During an interview on 02/19/25 at 10:58 a.m., the DON said CNA F should have worn the gown while providing care for Resident # 76 in isolation to prevent cross-contamination. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/19/25 at 11:59 a.m., CNA F said he should have worn the gown while providing incontinent care for Resident #76 because she was in on enhanced barrier precaution and to prevent Residents Affected - Some cross-contamination. CNA F said he had infection control training, including PPE. CNA F said the charge nurse monitored the aides during rounding.

During an interview on 02/19/25 at 3:04 p.m., the Administrator said CNA F should have worn the disposable gown while he provided care for Resident #76 on enhanced barrier precautions to prevent cross-contamination.

Record review of the facility undated in service on the importance of following up on ABP policy read in part . enhanced barrier precaution are essential to prevent the spread of infectious disease among staff and patients any patient placed on enhanced barrier precautions should be cared for in a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and multi drug resistance organism infection. when providing a daily living activities care for the patients, staff members must wear gowns . Goals . provide proper personal protective equipment as needed .

Record review of facility hand washing/hand hygiene dated 2001 MED - PASS, Inc. Revised August 2015 read in part . the facility considers hand washing the primary means to prevent the spread of infections . policy implementation #7b . before and after direct contact with resident . #7m . after removing gloves .#9 .

the use of gloves does not replace hand washing .

36918

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 676059