Health inspection·September 19, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facility failed to develop and implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 3 of 10 staff (LVN C, LVN D, and LVN E) reviewed for developing and implementing abuse and neglect policies. Residents Affected - Few The facility failed to develop and implement abuse policies for review of an employee EMR and criminal history at least once every 12 months. These failures could place residents at risk of abuse, neglect, and misappropriation of property. The findings included: Record review of the facility's policy and procedure on Background Screening Investigations (Revised March 2019) read in part: Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents . Record review of the facility's policy and procedure on Abuse Prevention Program (Revised August 2006) read in part: Our residents have the right to be free from abuse, neglect, and misappropriation of resident property, corporal punishment and involuntary seclusion .Our facility conducts employee background checks and will not knowingly employ and individual who has been convicted of abusing, neglecting, or mistreating individuals. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: Protocols for conducting employment background checks . Record review of LVN C's personnel file revealed a hire date of 7/23/21. Her EMR was ran on 7/16/21 and her criminal history was performed on 7/30/21. On 4/26/22, her EMR was ran again, and a background check was performed on 5/15/22, along with a sex offender check. Nothing was checked again until the State Surveyors asked for her chart on 9/18/24. On 9/18/24, LVN C's criminal history and EMR were checked. Her EMR was over 28 months due, and the criminal history was over 27 months due. Record review of LVN D's personnel file revealed a hire date of 9/27/22. Her criminal history was run on 9/12/22 as well as her EMR. Nothing was checked until the State Surveyors asked for her file on 9/18/24. On 9/18/24, her criminal history was run, as well as her EMR. Her EMR and criminal Page 1 of 10 676009 676009 09/19/2024 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0607 history checks were over 24 months due. Level of Harm - Minimal harm or potential for actual harm Record review of LVN E's personnel file revealed a hire date of 9/2/22. Her EMR was checked on 8/26/22 and her criminal history was checked on 8/31/22. Nothing was checked until the State Surveyors asked for her file on 9/18/24. On 9/18/24, her criminal history was run, as well as her EMR. Her EMR and criminal history checks were over 24 months due. Residents Affected - Few In an interview with the Human Resources Director on 9/19/24 at 10:30am, she said she started at the facility on 6/26/24. She said she would perform a criminal history check, license verification, EMR check, and sex offender check on everyone when they were first hired and then yearly thereafter. She said she noticed when she was pulling the files the State Surveyors requested, that some of the checks had not been done so she ran them. She said she did not know why they were not done because it was before she started. She planned on running everyone's at the beginning of the year so she could keep track of everyone. She said by not running the checks it could put residents at risk because an employee could have gotten in trouble and the facility would not know. In an interview with the Administrator on 9/19/24 at 11:15am, she said the previous Human Resources Director checked the staffing files near the annual hire date for each person. She said she was unaware the checks were not done and did not know why they were not done since the person no longer worked at the facility. 676009 Page 2 of 10 676009 09/19/2024 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 out of 12 residents (Resident #34) reviewed for ADL care. Residents Affected - Some The facility staff failed to provide timely incontinence care to Resident #34. This failure could place residents at risk of skin breakdown, pain, and infection. Findings include: Record review of Resident #34's undated face sheet, revealed an [AGE] year-old female admitted on [DATE], with an original admission date of 9/12/23. She had diagnoses of muscle weakness, muscle wasting and atrophy (wasting away of a part of the body), difficulty in walking, muscle spasms, osteoporosis (bone mineral density and bone mass decreases), need for assistance with personal care, lack of coordination, repeated falls, and Parkinson's Disease (unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Record review of Resident 34's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. She was substantial/max assist with toileting, personal hygiene, and upper body dressing. She was dependent with shower/baths, lower body dressing, and putting on/taking off footwear. She required substantial/max assist when rolling in bed, going from sit to lying, to go from lying to sitting, and for chair/bed to chair transfers. She was dependent with sitting to standing, toilet transfers, and tub/shower transfers. The resident was always incontinent of bowel and bladder. Record review of Resident #34's care plan, dated 1/30/24, revealed a Focus: Resident has an ADL selfcare performance deficit r/t impaired mobility, osteoporosis (bone mineral density and bone mass decreases), and muscle weakness. Goals: Resident will maintain current level of function in ADL performance through the review date. Interventions: Encourage resident to use call bell for assistance. Focus: The resident has bowel/bladder incontinence r/t impaired mobility and cognition. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Brief Use: The resident uses disposable briefs. Female Care Attendants to clean peri-area with each incontinence episode. Record review of Resident #34's progress notes revealed no notes which indicated the resident refused to be changed. In an interview on 9/17/24 at 10:43am, Resident #34 said the last time she was changed was at 3:00am that morning. She said she put her call light on, and it would stay on for a couple hours at a time and never got answered. She said the CNA only came in one time around 10:15am, when she had visitors. The CNA opened the door and the dog that was in the room barked and the CNA got scared and closed the door. The resident said the CNA had not been back since then. Resident #34 said she would often have to wait for extended periods of time to be changed. She said she would not tell anyone because it did not do any good. 676009 Page 3 of 10 676009 09/19/2024 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0677 Level of Harm - Minimal harm or potential for actual harm In an interview with CNA A on 9/17/24 at 10:53am, she said she had not had time to change Resident #34 because she was getting all the residents up out of bed, picking up breakfast trays, and helping get the residents into the shower beds for their showers. She said she told the nurse that she was unable to change the resident and the nurse went and informed the resident she could not be changed at that time because the CNA was picking up trays. Residents Affected - Some In an interview with LVN B on 9/17/24 at 10:56am, she said CNA A had not told her anything about Resident #34 that morning. She said she did not know anything about the resident needing to be changed. She said the CNAs round every 2 hours and PRN and change the residents at that time. The nurse said if the CNA was unable to change the resident, she could tell the nurse and she would do it. She said if residents sat in soiled briefs for extended amounts of time, it could cause skin break down. She said she would go check on the resident and change her. In an interview with the DON on 9/17/24 at 2:40pm, she said her expectations were for the CNAs to check residents every 2-3 hours and PRN. She said if the CNA was busy at that moment, they should tell the resident they would be back shortly, and it should not take more than 30min for them to go back to the resident. She said if they were really busy, they could inform the nurse or the DON and they could change the resident. The DON said if a resident was sitting in a soiled brief for extended periods of time it could cause UTIs and skin breakdown. Record review of the facility's policy and procedure on Activities of Daily Living (ADLs), Supporting (Revised Qtr 3, 2018) read in part: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene .Elimination . 676009 Page 4 of 10 676009 09/19/2024 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 2 of 12 months (July and August 2024) reviewed for RN coverage. The facility failed to ensure they had an RN on duty for the weekends during July and August 2024. This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: In an interview with the Administrator on 9/19/24 at 2:03pm, she said she did not have enough RN coverage on the weekends for July and August 2024. She said there was no point in printing the schedules and bringing it to the Surveyors because she knew she did not have an RN on the weekend. She said they had trouble keeping RNs, but she had just hired an RN Supervisor and an RN floor nurse at the end of August. She said having an RN provided a higher scope of practice for the facility and without one they were not able to perform certain procedures that only an RN could perform. In an interview with the DON on 9/19/24 at 2:16pm, she said she worked Monday through Friday from 8am to 5pm. She said she had the RNs round, review admissions, and do anything she would do if she were there. She said it was important to have RNs at the facility because they could do things LVNs could not like, remove PICC (long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) lines, place a suprapubic catheter (hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen), and perform dressing changes for PICC (long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) lines. She said not having an RN could put residents at risk because they were like a second pair of eyes with their assessment skills. The DON said when she was hired, she was told there were RNs, but she never saw them once she started, so she hired 2 and they stared at the end of August 2024. Record review of the facility's policy and procedure on Staffing (No revision date) read in part: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .A registered nurse (RN) must be onsite 8 consecutive hours a day, 7 days a week .Direct care staffing information per day .is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee. 676009 Page 5 of 10 676009 09/19/2024 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 11% based on 3 errors out of 26 opportunities, which involved 3 of 6 residents (Residents #22, #29 and #148) and 2 of 4 staff (MA A and LVN B) reviewed for medication errors. Residents Affected - Some 1. The facility failed to ensure MA A administered the correct dose of Nicotine gum to Resident #29. 2. The facility failed to ensure MA A administered the correct dose of Acetaminophen to Resident #22. 3. The facility failed to ensure LVN B administered Cefepime 2 gram IV to Resident #148 at the rate indicated on the pharmacy label. These failures could place residents at risk of inadequate therapeutic outcomes. Findings include: 1. Record review of Resident #29's face sheet, dated 9/19/24, reflected a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included acute respiratory failure (a condition in which your lungs have trouble loading your blood with oxygen or removing carbon dioxide), delusional disorders (a mental health condition that causes unshakable beliefs in somthing thats untrue), major depressive disorder and anxiety. Record review of Resident #29's MDS assessment, dated 8/14/24, reflected a BIMS score of 15 out of 15, which indicated intact cognition. She required assistance from staff with ADL care. Record review of Resident #29's Physician Orders for September 2024, reflected an order for Nicotine gum 4 mg give 1 gum by mouth every 4 hours for nicotine craving, order date 7/3/24. In an observation on 9/18/24 at 9:39 a.m. with MA A revealed she prepared and administered one Nicotine 2 mg gum to Resident #29 during the morning medication pass. In an interview on 9/18/24 at 1:06 p.m. LVN B said Resident #29 was on Nicotine 4 mg gum scheduled. In an interview on 9/18/24 at 1:07 p.m., MA A said it was a lot going on during the medication pass this morning and she did not concentrate on the dose. She said she normally verified the dosage, resident, time and medication. In an interview on 9/18/24 at 11:14 a.m., the DON said Resident #29 normally supplied the 4 mg dose. She said the facility had the 2 mg on hand and the medication aide should have clarified if she could have given two of the 2 mg gums. She said there was no risk to the patient. 2. Record review of Resident #22's face sheet, dated 9/19/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included fracture of shaft of humerus, acute 676009 Page 6 of 10 676009 09/19/2024 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0759 pain due to trauma, fracture of sternum, fracture of sacrum, and fracture of shaft of right tibia. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #22's admission MDS assessment, dated 6/26/24, reflected a BIMS score of 13 out of 15, which indicated intact cognition. She required assistance from staff with ADL care. Residents Affected - Some Record review of Resident #22's care plan, revised on 7/16/24, reflected she had acute pain related to multiple fractures. Interventions were to administer analgesia as per orders. Record review of Resident #22's Physician Orders for September 2024 reflected an order for Acetaminophen 650 mg give 2 tablets by mouth every 8 hours for pain, order date 6/20/24. In an observation and interview on 9/18/24 at 9:20 a.m. revealed MA A prepared and administered two tablets of Acetaminophen 325 mg to Resident #22. Observation of the MAR revealed the directive Acetaminophen 650 mg give 2 tablets. MA A said she knew how much of the medication to give by reviewing the MAR. She said she thought the MAR said to give two tablets of Acetaminophen 325 mg to equal 650 mg. She said she asked an unknown nurse previously and was informed to give two of the 325 mg tablets. In an interview on 9/18/24 at 9:35 a.m. the Regional Nurse said if anything on the MAR was different from what was available on the cart the medication aide should not give anything and notify the nurse. In an interview on 9/18/24 at 11:12 a.m., the DON said prior to administering the medication the medication aide should get clarification from the nurse if the order did not appear correct. She said the amount administered did not match the order and the order was not clear. 3. Record review of Resident #148's face sheet, dated 9/19/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included acute osteomyelitis (infection in the bone), type 2 diabetes, atherosclerotic heart disease (involves plaque buildup in artery walls), heart failure, and acute respiratory failure (a life threatening condition that occurs when your lungs cannot exchange oxygen and carbon dioxide properly). Record review of Resident #148's care plan, dated 9/19/24, reflected he required IV therapy and was at risk for adverse reactions, altered skin integrity and injury related to PICC line in place, receiving IV antibiotic, diagnosis osteomyelitis (infection of bone) and cellulitis (bacterial infection of the skin and the tissue beneath the skin) right foot/heel. Interventions were to give therapy as ordered. Record review of Resident #148's Physician Orders for September 2024 reflected an order for Cefepime IV 2 gm/100 mL use 2 gram intravenously every 12 hours for cellulitis of bilateral extremities until 10/11/24, order date 9/13/24. Observation and interview on 9/18/24 at 8:27 a.m. revealed LVN B prepared and connected Cefepime 2 gm/100 mL IV to Resident #148. She set the rate to flow at 100 mL per hour. Observation of the pharmacy label on the Cefepime read in part, Activate and mix 1 bag (2 gm) give intravenously every 12 hours until 10/12/24. Infuse over 30 minutes LVN B said the bag was 50 mL and she set the flow rate to 100 mL per hour so it could run over 30 minutes. LVN B said the bag was a 100 mL bag and she thought it was a 50 mL bag because it was small. She calculated the new flow rate and changed it to 200 mL per hour so the bag could run over 30 minutes. She said she normally verified the size of the bag 676009 Page 7 of 10 676009 09/19/2024 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some prior to administering but she did not check this time, she said she only verified the strength. She said if the flow rate was not set properly, she would not be following the orders. She said if the flow rate was not specified in the Physician order, she would follow the directive on the pharmacy label. In an interview on 9/19/24 at 11:22 a.m., the DON said the physicians order should give the flow rate and it was normally on the pharmacy label. She said the nurse should also get clarification. She said she was unsure how the pharmacy came up with how long the IV should run. In an interview on 9/19/24 at 1:33 p.m. the Administrator said she expected nursing staff to give medications timely, correctly, and according to the physician orders. Record review of the facility's Administering Medications policy, dated December 2018, read in part .Medications shall be administered in a safe and timely manner, and as prescribed . 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication 676009 Page 8 of 10 676009 09/19/2024 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (main kitchen) reviewed for sanitary kitchen. The facility failed to ensure the thermometer on the low temperature dishwashing machine was in working condition. This failure could place residents at risk for foodborne illness. The findings include: In an observation and interview on 9/19/24 at 12:50 p.m. of the dishwashing machine located in the kitchen area, Dishwasher A demonstrated how to use the machine by turning it on and running dishware through it. Observation of the two thermometers on the screen revealed they did not move. Dishwasher A said the thermometers did not work. In an interview on 9/19/24 at 1:00 p.m., Dishwasher A said (via Spanish interpretation from the Chef) the thermometers on the dishwashing machine had not been working for one week but when he touched the sides of the machine the doors burned him. In an interview on 9/19/24 at 1:12 p.m., the Dining Supervisor said the dishwashing company came to the facility 2 weeks ago and the dishwashing machine was not working at that time. She said the company did not say anything about the machine and was unsure if they left paperwork regarding the visit. In an interview on 9/19/24 at 1:15 p.m., the Chef said the dishwashing machine temperatures should be between 170-180 F to ensure the dishes were sanitized. He said kitchen staff would not know the temperature of the water without a functioning thermometer. He said the dishwashing machine was used for silverware and glassware and said there was no risk to the residents. In an interview on 9/19/24 at 2:25 p.m., the Administrator said she thought the dishwashing machine was already fixed. She said the kitchen staff informed her the dishwashing machine was a low temperature machine. Record review of the Dishwasher Temperature Log for September 2024 reflected there was no wash or rinse temperature recorded for breakfast, lunch, or dinner from 9/1/24 - 9/18/24. There was no wash or rinse temperature recorded for breakfast or lunch for 9/19/24. The PPM was 50 from 9/1/24 - 9/19/24. Record review of the facility's Dishwashing Machine Use policy, dated March 2010, read in part, .Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation . Policy Interpretation and Implementation . 2. Dishwashing machines that use hot water to sanitize must maintain the following wash solution temperatures: a. 150 F for stationary rack, dual temperature machines or multi-tank, conveyor, multi-temperature machines. B. 160 F for single tank, conveyor, dual temperature machines. C. 165 F for stationary rack, single temperature machines. 3. 676009 Page 9 of 10 676009 09/19/2024 Treemont Health Care Center 2501 Westerland Dr Houston, TX 77063

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Dishwashing machine hot water sanitation rinse temperatures may not be more than 194F, or less than: a. 165 F for stationary rack, single temperature machines. B. 180 F for all other machines . 7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. 8. The supervisor will check the calibration of the gauge weekly by: a. Running a secondary thermometer through the machine to compare temperatures; or b. using commercial temperature test strips following manufacturer's instructions. 9. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted Record review of the U.S. Food and Drug Administration Food Code dated 2022 read in part, .4-501;110 Mechanical Warewashing Equipment, Wash Solution Temperature . B. The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120F . 676009 Page 10 of 10