Health inspection·January 4, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an assessment that accurately reflected the resident's status for 1 of 6 residents (Resident #6) whose records were reviewed for MDS accuracy, in that: Residents Affected - Few The facility failed to ensure Resident #6's admission MDS accurately reflected his hearing loss and use of hearing aids. This failure by the facility placed the resident at risk of not receiving the care and services to meet his needs. Findings included: Review of Resident #6's face sheet dated 1/4/2024 revealed Resident #6 was an [AGE] year-old male who was admitted to the facility on [DATE] with a primary diagnosis of fracture of left femur. Other diagnoses include diabetes type 2, anemia, and anxiety. Record review of Resident #6's admission progress note dated 11/16/23 at 7:04 PM written by LVN A reflected that Resident#6 had hearing aids in both ears. Record review of Resident #6's admission MDS assessment dated [DATE], Section B0200 revealed the resident was determined to have normal, adequate hearing. On section B0300, the resident was marked as not using hearing aids. Record review revealed a progress note dated 12/4/23 at 5:59 PM written by LVN B that notated Resident #6's ability to hear is adequate and resident does not use a hearing aid. Record review of Resident #6's care plan dated 12/24/23 noted the resident had a communication problem. The communication problem was not defined or detailed in the care plan. The intervention for the communication problem was to monitor effectiveness of communication strategies and assistive devices. Hearing aids were not included in the care plan. During an interview on 1/4/24 at 11:50 AM, Resident #6 was unable to hear surveyor speaking to him unless a loud voice was used while leaning near his ear. Resident reported his ability to hear was poor without his hearing aids. He reported that he lost one of his hearing aids and the other had a dead battery. During an interview on 1/4/24 at 2:43 PM, DON said the nurse responsible for MDS accuracy was on bereavement leave. DON was not able to explain why Resident #6's hearing loss and use of hearing aids (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675714 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 675714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tomball Rehab & Nursing 815 N Peach St Tomball, TX 77375 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)