Health inspection·April 26, 2023

F 0842 03/01/2023, 03/04/2023, 03/06/2023, 03/22/2023, 04/03/2023, 04/04/2023, and 04/05/2023. Level of Harm - Minimal harm or potential for actual harm Record review of Resident#1s MAR for the Month of March 2023 indicated that MA A documented that Donepezil HCL 10 MG was not available on March 1, 7, 8, 9, and 10, 2023. MA B documented that Donepezil HCL 10mg was not available on March 4, 16, 17, 18, 20, 22, 24, and 25, 2023. Residents Affected - Some In an interview on 04/25/2023 at 2:00pm with the Hospice Nurse. She said that she was concerned that staff documented that Resident#1's Donepezil used to treat Alzheimer's was not available when she reviewed the MAR, but she confirmed the medication had been delivered and was in the facility. She said that the DON was aware of the error. In an interview on 04/25/2023 at 2:35pm with the NP. She said that she had concerns with documentation at the facility. She said that in a review of Resident #1's MAR she could see that staff entered residents' medication was not available when the medication was in the facility. She said that Resident#1's medication comes in a blister pack, and staff would chart that medication was available one day but not available the following day. She said that she expressed concerns with charting to the DON. She said the documentation error was with Resident #1's hospice medication to treat her Alzheimer's. In an interview and observation on 04/25/2023 at 3:30pm with the DON. She said that staff should only chart that medication is not available when the medication is not physically in the building follow by a note indicating why. She said that nursing staff should enter a nursing note to detail what steps were taking to resolve the issue if medication is not available. Observation of DON to review progress notes, and MAR for Resident#1 from admission date. She said that the facility recently had system updated and she wanted to ensure that there was no missing documentation due to the update. She said that MA A and MA B charted that Resident #1's Donepezil was not available when the medication had been administered. She said that Donepezil is used to treat Alzheimer. She said that both MA A and MA B denied that medication was not administered. She said that Resident#1 medications comes in a blister back making hard for missing doses if medication is in the building. She said that she did not complete an audit on documentation, and there was not an in-service started after the error was found. She said that both MA A and MA B involved were not at work, MA A would return on 04/28/23 and MA B would return on 05/02/2023. In an interview on 04/25/2023 at 3:35pm with the Administrator. She said that the DON is the clinical oversite for nursing staff. She said that she was not aware of there to be a concern for documentation. In an observation on 04/25/2023 at 3:45pm with DON. She was observed to unlock medication cart located on 200 hall and retrieve blister pack for Resident#1's Donepezil HCL 10 MG. In an attempt on 04/25/23 at 4:00pm to interview MA A by phone, efforts were unsuccessful. In an attempt on 04/25/23 at 4:05pm to interview MA B by phone, efforts were unsuccessful. In an interview on 04/26/2023 at 1:55pm with the Pharmacist. She said that the pharmacy filled and delivered Aricept 10mg on 02/27/23 and 04/04/2023 30 tablets in a blister packs. She said that both were delivered to the facility the same day medications were filled. She said that the generic name for Aricept was Donepezil. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 2 of 3 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0842 In an attempt on 04/26/23 at 2:20pm to interview MA B by phone, efforts were unsuccessful. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/26/2023 at 2:25pm with MA A. She said that she was familiar with Resident #1, and she did not remember there to be an issue with residents' medications not to be available. She said that if she charted that the medications were not available it would have been an error. She said that she could not remember the last time there was an in-service on charting and documentation. She said that if a medication is not available the Unit Manager, ADON, or DON can be notified to ensure that medications are made available to administered to residents. Residents Affected - Some Record review of in-service titled Charting dated 01/10/2023 read in part, Subjects covered: Time & Accuracy. Summary Conclusion: All charting must be done by the end of each shift. Charting must be done correctly accordance to resident need and change of care. Record review of the undated facility policy titled, Charting and Documentation, read in part, .All services provided to the resident, or any changes in the residents medical or mental condition, shall be documented in the resident's medical record. 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 3 of 3