Inspection·October 24, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lifting Resident #1's right leg straight in the air as he instructed Caregiver A on how to apply the white cream to the resident's under thigh area. The Wound Care Nurse was then seen putting Resident #1's leg back down straight on the bed, and the two staff members secured Resident #1's brief. The video had sound and it did not appear Resident #1 mentioned or appeared to have any pain. Record review of the Resident #1's hospital record dated 07/26/24, reflected Resident #1 admitted to the emergency department due to an altered mental status. The hospital record noted Resident #1' Family Member stated Resident #1 had complained of right hip pain for 1 and half weeks. It noted Resident #1 had tenderness around the right hip and pain with range of motion. The hospital document noted Resident #1 had an acute sub-capital right femoral neck fracture (neck of thighbone) without dislocation at the right hip joint. It also noted mild right hip joint osteoarthritis (joint breakdown). Record review of Resident #1 Medical Record from the Attending Surgeon at the hospital dated 07/26/2024 noted, Resident #1 was able to verbally tell her about the right hip pain. The Attending Surgeon noted upon starting the surgery the fracture site was not mobile and appeared subacute to chronic (bone fracture that started to heal). The Attending Surgeon noted the following: Addendum The fracture appeared subacute to chronic in nature, given the amount of fibrous tissue at the fracture site and small hematoma. It is my professional opinion that the EMS team that transported the patient to the hospital just prior to this admission was not at fault. In an interview on 10/22/24 at 12:08 PM, Resident #1's Family Member stated the family thought Resident #1's fracture resulted from the leg lift seen in the video. Resident #1's Family Member stated Resident #1 went to the hospital for something unrelated and asked the hospital to check her leg, because Resident #1 had complained about pain in the area. Resident #1's Family Member stated Resident #1 was diagnosed with a fracture while at the hospital. Resident #1's Family Member stated the resident had not fallen or had any accidents recently. The Family Member stated the facility did not report any incidents to the family which could have resulted in an injury. In an interview on 10/22/24 at 1:50 PM, Resident #1's Primary Care Physician stated he had no concerns with the care of Resident #1 while she was at the facility. The Primary Care Physician stated he stayed on top of Resident #1's care, especially since the resident's family member was very involved and liked to be updated frequently. He stated Resident #1 passed away recently, but it was not due to the care from the facility. He stated the resident had a lot of health issues. The Primary Care Physician stated he did not think lifting the resident's leg about 60-65 degrees could have caused the hip fracture. The Primary Care Physician stated he had not received any reports from the facility regarding Resident #1 and pain, or an increased amount of pain. He stated there was no change of condition reported to him regarding pain. He stated he did not receive a report of acute pain until Resident #1 was transported to the hospital on [DATE]. He stated the facility management was convinced the fracture occurred during transport to the hospital. The Primary Care Physician stated he assessed the resident a couple of days before she went to the hospital, and Resident #1 did not complain of pain. In an interview on 10/24/24 at 11:41 AM, the Wound Care Nurse stated he knew Resident #1 well, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 2 of 5 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 675153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Keller Rehab & Nursing 1150 Whitley Road Keller, TX 76248 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she did not complain at all. He stated he never received any complaints from the family. He stated Resident #1 was vocal and would tell you how she liked staff to provide care at times. The Wound Care Nurse stated Resident #1's legs were kind of forced inward, and it was easier at times to elevate her leg instead of turning her on her side when providing care. He stated he would generally turn the resident instead of lifting the leg, but it would depend on the limitations of whichever resident. The Wound Care Nurse stated in this instance he thought she asked him to lift her leg, because it felt better for her due to the wounds on her right leg. He stated he did not document her request. The Wound Care Nurse stated there was never a time when he lifted her leg and she complained of pain. The Wound Care Nurse stated there was no risk when he lifted Resident #1's leg, because the leg was not straight up, but just lifted, and he stated the resident was not in any pain. In an interview on 10/24/24 at 2:44 PM, the DON stated Resident #1 had a strong side and a weak side of her body. She stated Resident #1 would tell you if she wanted her care a certain way or if she was in pain. The DON stated the Wound Care Nurse would not have done Resident #1's care differently unless it was requested. The DON stated there was no documentation or any changes to the resident's care plan because it was probably a one-time request or a request in the moment. She stated if Resident #1 requested it more than once then it would have been care planned. The DON stated generally it was safer to turn a resident on their side instead of lifting the resident's leg. The DON stated the risk was the quality of care given to the resident if the resident did not request the leg lift. In an interview on 10/24/24 at 3:19 PM, the Administrator stated Resident #1's family would communicate with him and his staff often and never mentioned any concerns with the resident's leg being lifted. The Administrator stated the residents should be repositioned instead of lifting their legs in most instances. He stated he did not recall her being injured and she did not complain of pain, so he did not see the risk of the leg lift. The Administrator stated there was a care plan meeting after the resident returned from the hospital, in which Resident #1's family told the staff the resident's hip was fractured. He stated they believe the fracture occurred during the transport to the hospital, because he nor the DON received any report of any incidents with the resident prior to her transport to the hospital. The Administrator stated the staff should follow their policy and reposition the resident unless the resident requests otherwise. The Administrator stated he was not aware of the video or Resident #1's leg being lifted. The Administrator stated he did not see the risk, because the staff would be handled and re-trained. Record review of the facility's Incontinence Care policy, last revised 02/14/20, reflected the following: .Procedure Position on side turned away from caregiver. Position on back with knees flexed and feet flat on the bed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 3 of 5 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 675153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Keller Rehab & Nursing 1150 Whitley Road Keller, TX 76248 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 one of three residents (Resident #1) reviewed for infection control. Residents Affected - Few 1. The facility failed to ensure Caregiver A provided incontinence care using the proper technique when she wiped Resident #1's perineal area from back to front on 07/11/24. 2. The facility failed to ensure Caregiver A changed her gloves after she wiped Resident #1's perineal area on 07/11/24. These deficient practices could place residents at-risk for infections. Findings included: Record review of Resident #1's face sheet, dated 10/22/24, reflected the resident was an [AGE] year-old female, with an initial admission date of 05/10/21 and a readmission date of 08/04/24. Resident #1 had a diagnosis of cerebral infarction (brain tissue death due to blood blockage), irritant contact dermatitis due to fecal, urinary or dual incontinence (skin rash), chronic pain syndrome (persistent pain), muscle wasting atrophy (loss or thinning of muscle tissue), cognitive communication deficit (difficulty with communication), muscle weakness (lack of muscle strength), abnormal posture (chronic or rigid body position), edema (fluid buildup in body tissue), and acute pain due to trauma. Record review of Resident #1's MDS assessment dated [DATE], reflected Resident #1's had a BIMS score of 15, which meant the resident had intact cognition. Record review of Resident #1's care plan dated 08/07/24, reflected the following: (Resident Name) has recurrent chronic rash and recurrent cellulitis. Provide gentle peri-care after each incontinence episode. Observation of a video, dated 07/11/24, reflected the Wound Care Nurse and Caregiver A as they provided perineal and incontinence care to Resident #1. In the video Caregiver A was seen as she wiped Resident #1's vaginal area from bottom to top. Caregiver A was seen putting a white cream on Resident #1's vaginal area, and then put the same white cream on the under-thigh area of Resident #1's right leg without changing her gloves before she went to a different area of Resident #1's body. In an interview on 10/24/24 at 12:24 PM, Caregiver A stated staff should wipe from front to back when perineal care was provided to a resident. She stated gloves should be changed after each task or area. Caregiver A stated Resident #1's legs were pretty close to each other, and stated Resident #1 was not flexible. Caregiver A stated it was hard to wipe the resident a certain way, because she was not flexible. Caregiver A stated not wiping Resident #1 correctly could have caused an infection, and not changing her gloves could have caused contamination. In an interview on 10/24/24 at 2:44 PM, the DON stated staff should wipe a female resident from front to back when providing care. She stated the staff should not wipe back and forth, because that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 4 of 5 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 675153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House at Keller Rehab & Nursing 1150 Whitley Road Keller, TX 76248 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 - Few would cause infection. The DON stated when cleansing or putting cream on different areas of the body, the staff should remove gloves, sanitize, then put on a new pair of gloves before tending to another area of the resident's body to prevent cross-contamination. The DON stated all staff were trained on infection control and perineal care. In an interview on 10/24/24 at 3:19 PM, the Administrator stated the staff had been trained on infection control and perineal care. He stated staff should know when to change their gloves and how to provide perineal care. He stated residents should be wiped from front to back when staff provide perineal care. The Administrator stated getting a citation for infection control would be a learning experience for his staff, as he has tried to train and re-train them on important subjects like infection control. The Administrator stated the risk of not changing gloves between areas of the body and wiping incorrectly was infection. Record review of the facility's Incontinent Care policy, last revised on 02/14/20, reflected the following: .Procedure .11. Cleanse per-area and buttocks with cleansing agent wiping from front of the perineum toward rectum. 12. Dry peri-area and buttocks from front to back 13. Apply skin protectant products, if needed and, or as ordered, per manufacturer's instructions . 15. Remove and discard gloves . Record review of an in-service titled, Covid-19 and Infection Control, dated 08/10/24, reflected the following: When to Perform Hand Hygiene Clean your hands: If hands will be moving from a contaminated body site to a clean body site during patient care . A general policy on infection control was requested on 10/22/24 and not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 5 of 5