Park Manor of Humble

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure nurses monitored Resident #1 after an unwitnessed fall on 5/1/26 according to the facility policy. The facility failed to document the monitoring of Resident #1's unwitnessed fall on 5/1/26 and 5/2/26. This failure could place residents at risk for a delay in care, injury, and hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily and systematically organized in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #1) reviewed for clinical records. The facility failed to document the monitoring of Resident #1's unwitnessed fall on 5/1/26 and 5/2/26 in a timely manner. This failure could place residents at risk for a delay in care, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 9%, based on 3 errors out of 31 opportunities, which involved 2 of 5 residents (Resident #29 and #114) and 2 of 4 staff (MA C and MA L) reviewed for medication administration. MA C did not offer or apply Lidocaine patches to all areas indicated in the MD order and administered the wrong Iron supplement to Resident #114 on 4/8/26. MA L did not administer the correct dose of Clearlax (used for the relief of occasional constipation) to Resident #29 on 4/8/26. These failures could place residents at risk of ineffective therapeutic outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature control, and only permit only authorized personnel to have access to the keys for 2 of 5 residents (Resident #115 and Resident #48) reviewed for storage of medications. The facility failed to keep Resident #115's medication secured. Four plastic eye dropper bottles of Eyes Alive (Carboxymethylcellulose sodium 0.5%) were found on Resident #115's bedside tray table. Resident #115 did not have orders to self-administer. The facility failed to ensure Resident #48's Xiidra eye drops (used to treat the signs and symptoms of dry eye disease) were stored at the proper temperature according to the medication label. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of 5 residents (Resident #67) reviewed for infection control. CNA A failed to cleanse the tip of the penis while performing incontinent care for Resident #67. CNA A failed to maintain a sanitary environment by placing packages of used supplies back onto a clean linen cart.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency) in accordance with State law through established procedures for 2 of 6 residents (Residents #39 and #52) reviewed for reporting allegations of abuse, neglect, and exploitation. -The facility failed to report an allegation of abuse of Resident #39 and Resident #52 to the State Agency within the two-hour timeframe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practices, the comprehensive care plan, and the residents' choices and based on the comprehensive assessment of a resident for 1 of 6 residents (Resident #42) reviewed for quality of care. The facility failed to obtain physician orders for an abrasion that Resident #42 sustained on his left leg after an incident on 2/1/25. This failure could place residents at risk of infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an effective pest control program to remain free of pests and rodents for four of four residents and one of four halls. The facility failed to ensure the building is free of cockroaches. This failure could place residents at risk of, infection, skin irritation, allergies, which could result in unsanitary living conditions and decline in health and well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 3 of 6 residents (Resident #1, #2, and #3) reviewed for pest control. -Resident #1 had one medium sized roach crawling on the wall behind her bed. -Resident #2 had several medium and small size roaches crawling on the floor and wall next to her bed. -Resident #3 had a small roach crawling on the wall in her room. This failure could place residents at risk of residing in an environment with pests.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 3 (Resident #1, #5, and #7) of 10 residents reviewed for residents' rights in that: -Resident #1 was found to have soiled (feces) wipes left in her brief until her scheduled shower time. -Residents #5 and #7 did not have their briefs changed in a timely manner according to the facility's policy and procedures. These deficient practices could place residents at risk for impaired dignity, loss of self-worth, and a decline in psychosocial well-being.

Inspectors wroteBased on interview and record review, that facility failed to extend to the resident representative ' s the right to make decisions on behalf of the resident for 1 of 10 residents (CR#1) reviewed for resident rights in that. 1. The facility failed to establish if CR#1 wanted to the leave the facility to the hospital when requested by the Resident Representative (RR) when he was alert and oriented times four. 2. The facility failed to arrange emergency transportation to local hospital when requested by RR for CR#1 when he expressed having trouble breathing on [DATE] and complained of abdominal pain with diarrhea. CR#1 was wheeled to a local hospital on [DATE] and expired while at the hospital on [DATE]. - An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:43pm. [...]

Inspectors wroteBased on observation, interview, and record review , the facility failed to consult with the resident's physician; and notify the resident representative for 1 of 10 residents (CR#1) reviewed for change of condition, in that, 1. LVN A failed to immediately notify the physician on [DATE] when CR#1 was observed with diarrhea, and LVN A failed to immediately notify the physician when CR#1 said he was having trouble breathing on [DATE]. CR#1 was admitted to a local hospital on [DATE] and died while in the hospital on [DATE]. 2. The facility failed to establish if CR#1 wanted to the leave the facility to the hospital when requested by the Resident Representative (RR) when he was alert and oriented times four. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] 11:27am. [...]

Inspectors wroteBased on, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (CR #1) out of 10 residents reviewed for quality of care in that: 1-The facility failed to obtain physician orders on [DATE] prior to treating CR#1 with loperamide to treat diarrhea. 2-The facility failed to arrange emergency transportation to local hospital when requested by RR for CR#1 when he expressed having trouble breathing on [DATE] and complained of abdominal pain with diarrhea. CR#1 was wheeled to a local hospital on [DATE] and expired while at the hospital on [DATE]. 3-The facility failed to establish if CR#1 wanted to the leave the facility to the hospital when requested by the Resident Representative (RR) when he was alert and oriented times four. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (Resident #2) of 5 residents reviewed for respiratory care. -The facility failed to ensure Resident #2's physician orders for oxygen administration were being followed. This failure placed residents who received oxygen therapy at risk of for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 (Resident #1) of 5 residents reviewed for resident call system. -The facility failed to ensure Resident #1's call light was in working order. This failure could have placed residents at risk of not receiving assistance when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents' choices for 1 of 8 residents (Resident #76) reviewed for quality of care. The facility failed to ensure Resident #76 was assessed by a licensed nurse in a timely manner when she began to show signs and symptoms of hypoglycemia (low blood sugar). CNA K reported the hypoglycemic episode to RN A, who did not respond to the incident. CNA K provided Resident #76 with juice and sugar packets and the resident was not assessed until the following shift, approximately 1 hour later. This failure could place residents at risk of hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 9 residents (Resident #107) reviewed for significant medication errors. -The facility failed to administer the correct dose of Xtandi (a cancer medication) to Resident #107 as ordered by the Physician. This failure could place residents at risk of not receiving the therapeutic effect of the medication.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an effective pest control program so that it remains free of pests for 1 (Resident #53) of 24 residents and one area (The Conference Room) reviewed for pests. -The facility failed to ensure the building was free of cockroaches and fruit flies. These failures could put residents at risk of, infection, allergies, skin irritation, unsanitary living conditions and decline in health and well-being.