Health inspection·September 30, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview, and record review, the facility failed to ensure allegations of abuse and neglect are thoroughly investigated and report results of the investigation to the stage agency within 5 working days of the incident for 2 of 9 residents (Resident #50 and #84) reviewed for allegations of neglect as evidence by: 1. The facility failed to report an unwitnessed fall to the state agency when Resident #84 was found on the floor had a large hematoma to the top of her head and was transferred to the hospital . Resident #84 could not state how she fell. 2. The facility failed to report an unwitnessed fall to the state agency when Resident #50 was found on the floor. Resident #50 was sent to hospital on 7/25/23 and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. These failures could place residents at the facility not having their complaints and concerns reported and investigated for potential mental, physical, or emotional abuse . The findings included: Resident #84 Resident #84 was 78 years admitted to the facility on [DATE] with diagnoses of age-related physical debility, pressure ulcer of sacral region, stage 4 (largest and deepest of all bedsore stages) lack of coordination, cachexia (excessive loss of weight), and cerebral infarction (Stroke). Resident #84 quarterly MDS dated [DATE] was revealed that she required total assistance of at least 2 persons assist with transfers from bed, wheelchair. According to the annual MDS she had unsteady balance and was not able to stabilize with staff assistance and used a rolling wheelchair for mobility. Her BIMS score was 03 (severe cognitive impairment). Record review of Resident #84's care plan, created dated 04/05/23 indicated she had impaired cognitive function and impaired thought processes related to dementia limited physical mobility related to weakness, increased risk for infection, falls, impaired verbal communication, loss of ability to do ADLs. Communication problem related to intrinsic and extrinsic factors such as: slurred/mumbled speech says few words difficult to understand. Interventions included communication, ask yes/no questions in order to determine the resident's needs. Ambulation: The resident requires (supervision Page 1 of 24 676221 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0609 assistance) by staff to walk and anticipate and meet needs. Level of Harm - Minimal harm or potential for actual harm Review of the facility Incident report revealed nursing staff (agency nurse) completed a report for Resident #84's fall. On 9/17/23 at 8.40 PM: Incident Note: This writer was notified by resident's roommate, that resident is laying on the floor . Writer went into resident's room to check on resident. Resident found lying face down on the floor by the bedside. Resident assisted to lay on her back by this writer and other staff members. Total head to toe assessment done. Large sized hematoma noted to the left side of the forehead above the left eye area. Description: Resident was unable to give description Residents Affected - Some Interview with the DON on 9/24/23 at 2:35 PM revealed Resident #84 fell in her room on 9/17/23 at about 8:40 PM, and had a bump to her head, was sent to the hospital, X-ray was done in the hospital. DON was asked why incident was not investigated and report to the state agency was not notified. DON said we are not supposed to report incident if resident were able to state how she fell. During interviews on 9/24/23 between 8:25 a.m. and 6:41 PM facility staffs said Resident #84 was very confused to self and would not be able to identify how she fell. Interview on 9/29/23 at 4:00 PM with RN B, who worked the weekend r Resident revealed #84 fell. She was taking care of another hall when Resident #84' roommate called her. She went to Resident room and found Resident #84 on the floor. Roommate curtain was closed, and she did not know what happened. Resident #84 was not able to verbalize how she fell , RN A said Resident #84 was very confused and her roommate. Resident #50 Review of Resident #50's face sheet revealed Resident #50 was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on [DATE] with a diagnoses of mild intellectual disabilities ( when there, are limits to a person's ability to learn at an expected level and function in daily life), hyperlipidemia (high lipid fat blood level in the blood), personal history of traumatic brain injury, epilepsy, obstructive, reflux uropathy, developmental disorder of scholastic skills , epilepsy (abnormal electrical activity in the brain), not intractable, without status epilepticus, unspecified fall. Review of Resident #50's quarterly MDS dated [DATE] was revealed that he required extensive assistance of at least 1 person assist for transfers from bed, chair, wheelchair, and standing position. According to the quarterly MDS he had unsteady balance and was not able to stabilize with staff assistance and used a wheelchair and rolling walker as his mobility . Record review of Resident #50's health notes dated 7/26/23 revealed he was sent to hospital and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. Interview with C.NA A on 9/8/23 at 2:54 PM, revealed she said she worked with Resident #50 since April 2023. He was a 1 person assist and was sometimes able to verbalize his needs but was very confused. Interview with C.NA B on 9/8/23 at 2:57 PM, revealed she worked with Resident #50 since April 2023. He was 1 person assist and was sometimes able to verbalize his needs but was very confused not able 676221 Page 2 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0609 to explain himself when he fell. Level of Harm - Minimal harm or potential for actual harm Interview with LVN, MDS on 9/8/23 at 3:53 PM, via telephone revealed she completed Medicare MDS only and RN MDS completed Medicaid MDS assessment, and Resident #50 was not her resident. She said Resident #50 was very confused and each fall should be care plan and fall updated. Residents Affected - Some Interview with the DON on 9/24/23 at 2:35PM, she said Resident #84 fell in his room on 9/17/23 at about 9:40 AM. She stated he had a bump to his head, was sent to the hospital, and CT scan was done in the hospital. The DON was asked why the incident was not investigated and reported to the state agency. DON said, we are not supposed to report incident if resident were able to state how he fell. During interviews on 9/24/23 between 8:25 a.m. and 6:41 PM facility staffs said Resident #50's was very confused to self and would not be able to identify how he fell. Interviews the DON and Administrator on 9/26/23 at 2:30 PM regarding thoroughly investigating and reporting incidents and accidents to the state agency revealed that following a fall with injury, they only reported falls with injury if residents was not able to tell the nursing staff how they fell and were following the state guidelines of reporting incident / accident. She said the falls were not suspicious of abuse and that was why it was not investigated. Record review of the Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated July 10,2019, (Long -Term Care Regulatory Provider Letter) indicated:2.0 Policy details and provider responsibilities. 2.1. Incidents that a NF Must report to HHSC and the time frames for reporting . Abuse, Neglect Exploitation Death due to unusual circumstances A missing resident Misappropriation Drug Theft Suspicious injuries of unknown source Fire Emergency situations that pose a threat to resident health and Safety Record Review of the facility's policy titled Abuse Investigations, (revised April 2017) read in 676221 Page 3 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some part . All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required state or local laws, within (5) working days of the reported incident. 676221 Page 4 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 4 residents reviewed for care plans (Resident #50) - The facility failed to care plan Resident #50's risk and history of falls and to put interventions in place to prevent further falls. The care plan was not updated or revised after each fall. An Immediate Jeopardy (IJ) was identified on 09/24/23 at 2:00 PM. While the IJ was removed on 09/26/23 at 4:32 AM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of not having individual needs met and decreased the quality of life to prevent further falls. Findings included: Review of Resident #50's face sheet revealed Resident #50 was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on [DATE] with a diagnoses of mild intellectual disabilities ( when there are limits to a person's ability to learn at an expected level and function in daily life), hyperlipidemia (high lipid fat blood level in the blood), personal history of traumatic brain injury, epilepsy, obstructive, reflux uropathy, developmental disorder of scholastic skills, epilepsy (abnormal electrical activity in the brain), not intractable, without status epilepticus, , unspecified fall. Resident #50 quarterly MDS dated [DATE] was also coded that he required extensive assistance of at least 1 person assist for transfers from bed, chair, wheelchair, and standing position. According to the quarterly MDS he had unsteady balance and was not able to stabilize with staff assistance and used a wheelchair and rolling walker as his mobility. Record review of Resident #50's care plan dated 11/24/22 revealed the care plan did not contain a focus area for falls. Record review of Resident #50's EMR revealed the resident experienced falls on the following dates 10/30/22, 12/2/22, 12/7/22, 1/5/2023, 3/18/23, 3/25/2023, 6/9/2023, 6/30/2023, 7/25/2023, 7/26/2023, 8/8/2023, 8/15/2023, 8/20/2023, 9/2/2023, and 9/3/2023. These falls were updated on 9/8/2023 by the MDS RN. Record review of Resident #50's progress notes revealed the resident experienced an unwitnessed fall on 7/25/23. The resident was sent to the hospital and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. On 9/28/23 Resident #50 the surveyor observed with right upper eyebrow large bruise and strips to the forehead . 676221 Page 5 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview with the DON on 9/8/23 at 4:29PM regarding Resident # 50's falls revealed she was responsible for looking to see if the care plans were revised and to see if it the interventions used were working. She said she could not remember when the care plan was modified for Resident #50. She said the root course for Resident #50's fall was for seizures. She said the floor mat was moved away because it does not prevent falls, it helps to prevent injuries. DON said Resident #50 was not on a low bed because it was inappropriate for him . She said MDS RN did the care plan for all Resident #50 falls , and he was in the facility. DON said she forget to document why the floor mat and low bed was not used on the care plan. Interview with the MDS-RN on 09/08/2023 at 4:46 PM revealed he had just added each fall from 10/30/22, 12/2/22, 12/7/22, 1/5/2023, 3/18/23, 3/25/2023, 6/9/2023, 6/30/2023, 7/25/2023, 7/26/2023, 8/8/2023, 8/15/2023, 8/20/2023, 9/2/2023, and 9/3/2023. to the care plan on 09/08/2023 . Interview on 09/08/2023 at 07:40 p.m. with the Director of Rehab, revealed Resident #50 may have used a rolling walker during therapy. He said there was a progress note he completed on 7/27/2023 regarding bed mobility, supervision, the use of bed rails. Low bed, floor mat, transfer standby assist, and for the nurses implement those devices Interview on 09/08/23 at 08: 20 PM with the Administrator, revealed all the staffs were responsible for addressing and ensuring the wellbeing of the residents. He said when a fall occurs an incident report should be completed by the floor nurse and the DON is alerted. He said a fall that results in a change of condition will be addressed in the morning meetings by the IDT the following day. He said his interventions was to ensure appropriate care plan to addressed individual needs immediately. He said fall interventions should have been addressed and updated to Resident #50's care plan at each fall or change of condition and they were not. The Administrator said it was the DON, MDS RN, and Therapy's responsibility to ensure those updates of the care plan. He said he signs off on all the incident reports and he was not aware of each of Resident #50's falls. He said Resident #50's falls would be discussed in the following morning meeting. This was determined to be an Immediate Jeopardy (IJ) on 09/24/23 at 2:00 PM. The DON, was notified. The DON was provided the Immediate Jeopardy template on 09/24/23 via email at 2:00 PM. The following Plan of Removal was submitted and accepted on 09/26/23 at 4:32 AM. Plan of Removal Immediate action: FOR REMOVAL OF IMMEDIATE Jeopardy On September 5th, 2023, an annual survey was initiated. On September 24th, 2023, at approximately 1:00 pm, the facility was notified by the surveyor that an immediate jeopardy had been called and needed to submit a letter of credible allegation. The Facility respectfully submits this Letter of Credible Allegation pursuant to Federal and State regulatory requirements. Issue: F-Tag 656: Facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet Resident # 50's needs due to frequent falls and with major injury on 07/26/2023. The facility failed to care plan Resident # 50's risk/history of falls and to put interventions in place to prevent further falls leading to a fall with 676221 Page 6 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0656 major injury on 07/26/2023. Level of Harm - Immediate jeopardy to resident health or safety Done for those affected: On 09/24/2023 a new fall risk assessment was performed on resident #50 by DON, MDS Nurse and Rehabilitation Director. Completed on 09/24/2023. Residents Affected - Few On 09/24/2023 the care plan was updated to include current interventions to minimize injuries from further falls. Completed on 09/24/2023. On 09/24/2023 PCP and medical director were notified of current interventions in place to minimize injuries and agreed with interventions. Completed on 09/24/2023. On 09/24/2023 RP was notified of current interventions in place to minimize injuries and agreed with interventions. Completed on 09/24/2023. On 09/24/2023 Head to toe assessment completed Resident # 50 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 09/24/2023. On 09/24/2023 DON and nurse managers audited residents who are at fall risk and started updating care plans as appropriate for those residents ensuring current interventions as appropriate. Care plans for residents with fall risk updated and completed on 9/25/23. Identify residents who could be affected: On 09/24/2023 Administrator and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified to be affected by the same deficient practice. Completed on 09/24/2023. Action Taken: On 09/24/2023 the care plan for resident # 50 was updated to reflect current interventions and assistive devices. Completed on 09/24/2023. Effective immediately (after care plan updated) on 09/24/2023, the Administrator / DON and/or designee began re-education to all staff on the facility fall risk assessment, care planning, implementing interventions, and on the use of assistive devices for resident # 50. Staff present in the facility on 09/24/2023 were in-serviced on 09/24/2023. Staff not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed. On 09/24/2023 All nurse managers were educated on ensuring resident care plans are updated after falls to include appropriate interventions and assistive devices, where applicable, either in person or by phone. Staff does not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed for that individual. On 09/24/2023 all residents with falls in the last 30 days were reviewed for any injuries that could be considered a major injury and care plans were reviewed. Completed on 9/24/23. Those that are not scheduled to work on 09/24/2023 will have the re-education completed prior to 676221 Page 7 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0656 the start of their next scheduled shift. Phone calls made to nurses not currently working. Level of Harm - Immediate jeopardy to resident health or safety On 09/24/2023, the Administrator, DON and Director of Rehabilitation Services provided one to one reeducation to all LVNs, RNs and nurse managers on adequate supervision, assistive devices, fall precautions, person-centered care planning with measurable objectives and timeframe, and adequate interventions. Education was completed on 09/25/2023. Residents Affected - Few On 09/24/2023 the Care plan policy was reviewed by Administrator, VP of Operations, DON, MDS-RN, and nursing management. In-service provided by VP of Operations to above-listed individuals regarding the importance of comprehensive care plans and the update of care plans after a significant change, to include measurable outcomes. Completed on 09/24/2023. On 09/24/2023 administrator and DON in-serviced nurse managers on reporting and recognizing major injuries. Completed on 09/24/2023. On 09/24/2023 DON, MDS nurse and rehabilitation director assessed resident # 50 for interventions to minimize the risk of falls and injuries. Completed on 9/24/23. Surveyor Monitored the plan of removal and interview as follows: Observations were started on 09/24/23 at different times revealed the staffs knew how to minimize falls and injuries, by the use of floor mat, bed in lower position, call light within reached, rooms not cluttered. 3:00 PM, 4:00PM, 09/25/23, 8:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM, 09/26/23, 9:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM, 09/27/23 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 6:00 PM, 7:30 PM, 09/28/23, 9:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 6:00 PM, 09/29/23, 12:40 PM, 1:30 PM, 3:45 PM, 5:00 PM and continued through 09/30/23, 10:30 AM, 11:30 AM, and 12:30 PM, 1:30PM. Observations were started on 09/24/23 and continued through 09/30/23. Observation of Residents #19, #50, #62, #84 revealed adaptive devices of floor mat, low bed, bedrooms were free of clutter and were available for residents at risk for falls. Interviews were conducted on 09/24/23, 09/25/23, 09/26/23, 09/27/23, 09/28/23, 09/29/23 , 09/30/23 with over 20 staffs across all 6:00 AM to 6:00PM and 6:00PM to 6:00 AM shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS RN, CNA A, CNA B, CNA C, C.NA D LVN A, LVN B, LVN C, LVN D, LVN E, MA A, CNA H, CNA E, CNA F, CNA G, PT, OTA and RN A. All staff interviewed verbalized adequate understanding of plan of remove training received including Universal Fall Precautions policy/procedures, star program (residents that were high risk for fall, stars were placed on the entrance door), [NAME] system, and Fall Prevention Procedures. Record review of the facility POR Binder revealed: Over 25 Staffs were in-serviced on 09/26/23, 09/27/23 and 09/28/23 regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls care plan. Reporting, incidents, [NAME] system and Fall Prevention Procedures. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights. During an interview on 09/26/2023 at 1:59p.m. with DON, RN said, she believed the facility 676221 Page 8 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few currently had an IJ because of the resident' s history of falls. She said the resident#50 did not need a 1 on 1 supervision, but because he had so many falls, it was a concern. She said there was no high risk falls care plan and she did not have a system in place to identify high risk for falls residents ( the Star program) to have nursing staffs monitored residents closely and document each falls. During an interview on 09/26/2023 at 2:32p.m. the Administrator said he believed the facility is currently has an IJ because there was Resident #50 that fell and sustained a major injury. He said he made sure that everybody understands how important about supervising residents. He said a big part of the morning meetings and meeting with quality assurance, is to make sure high-risk residents for fall were monitored. He said if there is a change in the environment, staff should know those changes and adapt to those changes. He said it is hard to do your job if you do not understand how to do certain things. He said he knows how staff is interacting with the residents by monitoring, walking around and observing what is happening on the floor and educating them with in-service trainings and the use of assistive device to prevent fall and minimized injury. During an interview on 09/26/2023 at 1:33p.m. the ADON, LVN said, she doesn't know why the facility has an IJ. She said she knew the incident that happened with the resident and that he had a fall. She said she was not working the day the resident had the fall. She said she could improve her work by being thorough with her documentation. She said all staff need to always monitor the residents at the facility. She said the high fall risk residents she be around the nurse's station so that someone can keep a close eye on the residents. She said things would have gone differently if she was present at work during the incident with the resident. She said would have put interventions in place and care planned the falls based on how the falls happened. She said some of the trainings for staff are ongoing. She said she had a broad view on how to care for the residents. She said the purpose of having in-service training is so that staff understands how to take care of the residents and document care plan. She said things change and staff must continue to receive training to adapt to those changes and star fall program. During an interview on 09/28/2023 at 1:42 p.m. with MDS RN, RN said the facility has an IJ because there was a resident with frequent falls, and they did not put assistive device to prevent him for falling and it resulted in a major injury. He said they went back and reviewed what was going on with the resident. He said for now on he is going to pay closer attention to the residents that are high risk for falls care plan He said the care plans will be closely directed to the resident. He said he will work closer with the nursing staffs and document to show that the residents are being monitored. He said the care plans was not being done correctly since he has been at the facility. He said the care plans needs to be individualized on falls. The Administrator was informed the Immediate Jeopardy was removed on 09/28/23 at 9:46 AM. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. 676221 Page 9 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #50) reviewed for free of accidents, hazards, supervision, and devices., in that: 1. The facility failed to provide and utilize assistive devices for Resident #50 who had experienced multiple falls and unwitnessed fall on 7/25/23. Interventions including assistive devices were not put in place after a fall on 07/25/23 resulting in hospitalization and resident fell again on 07/26/23 resulting in a major head injury and another hospitalization 2. The facility failed to implement interventions after each fall incident for Resident #50 on 10/30/22, 12/2/22, 12/7/22, 1/5/2023, 3/18/23, 3/25/2023, 6/9/2023, 6/30/2023, 7/25/2023, 7/26/2023, 8/8/2023, 8/15/2023, 8/20/2023, 9/2/2023 and 9/3/2023. No revisions were made to the care plan after all of the falls listed until surveyor intervention on 09/08/23. 3. The facility failed to follow their Fall Prevention Policy to include providing additional interventions when Resident #50 had multiple falls An Immediate Jeopardy (IJ) was identified on 09/24/23 at 2:00 PM. While the IJ was removed on 09/26/23 at 4:32 AM, the facility remained out of compliance at a scope of isolated and severity of actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could affect residents who were fall risk and place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings include: Review of Resident #50's face sheet revealed Resident #50 was a [AGE] year-old male who was admitted to the facility on [DATE], re-admission on [DATE] with a diagnoses of mild intellectual disabilities ( when there, are limits to a person's ability to learn at an expected level and function in daily life), hyperlipidemia (high lipid fat blood level in the blood), personal history of traumatic brain injury, epilepsy, obstructive, reflux uropathy, developmental disorder of scholastic skills, epilepsy (abnormal electrical activity in the brain), not intractable, without status epilepticus, , unspecified fall. Resident #50 quarterly MDS dated [DATE] was also coded that he required extensive assistance of at least 1 person assist for transfers from bed, chair, wheelchair, and standing position. According to the quarterly MDS he had unsteady balance and was not able to stabilize with staff assistance and used a wheelchair and rolling walker as his mobility. Record review of Resident #50's EMR revealed the resident experienced falls 10/30/22, 12/2/22, 12/7/22, 1/5/2023, 3/18/23, 3/25/2023, 6/9/2023, 6/30/2023, 7/25/2023, 7/26/2023, 8/8/2023, 8/15/2023, 8/20/2023, 9/2/2023, and 9/3/2023. These falls were listed on 9/8/2023 by MDS RN. Record review of Resident #50's progress notes revealed resident experienced an unwitnessed fall on 7/25/23. The resident was sent to hospital and returned 12:30 AM on 7/26/2023. On 7/26/2023 at 9:00 676221 Page 10 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few AM, Resident #50 experienced another fall that resulted in a major injury (large hematoma on left top head) and was transported back to hospital. On 9/8/23 Resident #50 was observed with right upper eyebrow large bruise and strips to the forehead. Observation on 9/5/23 at 10:00 AM, 11:00 AM, 2:00 PM, 4:00 PM revealed Resident #50 was not on a low bed and had no floor mat . He was talking to himself and occasionally yelling out help. Observation indicated he would answer to his name when called out loudly. Observation on 9/6/23 at 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM revealed Resident #50 was not on a low bed and had no floor mat . Observation on 9/7/23 at 10:00 AM, 12:00 PM, 3:00 PM, 4:00 PM revealed Resident #50 was not on a low bed and had no floor mat . Observation on 9/8/23 at 11:00 AM, 1:00 PM, 2:00 PM, 4:00 PM revealed Resident #50 was not on a low bed and had no floor mat. Observation on 9/5/23 at 10:00 AM, 11:00 AM, 2:00 PM, 4:00 PM revealed Resident #50 was not on a low bed and had no floor mat. During an interview with CNA A on 09/08/2023 at 2:54 PM, regarding falls/seizures , she said she would ensure residents were safe by moving any objects that could cause harm to resident and would call the nurse if resident was on the floor to assess resident. CNA A said Resident #50 was not on a low bed with floor mat and was on regular bed. During an interview with CNA B on 09/08/2023 at 2:57 p.m., regarding falls/seizures, she said she ensured resident were safe by moving things that could hurt the away. She would call the nurse assess the resident. CNA B said Resident #50 was not on a low bed with floor mat. Interview with the DON on 9/8/23 at 4:29PM said, regarding Resident # 50's falls, she said she was responsible for looking to see if the care plan was revised and to see if the interventions used were working. She said she cannot remember when the care plan was modified for Resident #50. She said the root course for Resident #50's fall was seizures. She said the floor mat was moved away because it does not prevent falls, it helps to prevent injuries. DON said Resident #50 was not on a low bed because it was not appropriate for him. Interview with ADON, LVN, on 9/8/23 at 3:00 p.m., she said Resident #50 was moved from 400 hall to 100 hall due to frequent falls and he was being monitored closely every 1hour he was not on a low bed with floor mat. Interview on 09/08/2023 at 07:40 PM with the Director of Rehab, said Resident #50 may have used a rolling walker during therapy. He said there was a progress note he completed on 7/27/2023 regarding bed mobility, supervision, the use of bed rails. Low bed, floor mat, and transfer standby assist and the nurses implement those devices. Interview on 09/08/23 at 08: 20 PM with the Administrator, said all the staff are responsible for addressing and ensuring the wellbeing of the residents. He said when a fall occurs an incident report should be completed by the floor nurse and the DON is alerted. He said a fall that results in a change of condition will be addressed in the morning meetings by the IDT the following day. He said 676221 Page 11 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few interventions if not appropriate, will be to update the care plan immediately when discovered. He said fall interventions should have been addressed and updated to Resident #50's care plan at each fall/change of condition and they were not. The Administrator said it was the DON, MDS, and Therapy's responsibility to ensure those updates on the care planW. He said he signs off on all the incident reports and he was not aware of each of Resident #50's falls. He said Resident #50's fall would be discussed in the following morning meeting. Record review of the facility's policy dated (October 2022 Review). F689-Free of Accident Hazards Supervision Devices 42 C.F.R. 483.25(d)(1)(2): Fall Prevention Program. Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . Definitions: A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . 5. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. ii. Place Fall Prevention Indicator ( star program) on the name plate to resident's room door. iii. Place Fall Prevention Indicator on resident's wheelchair. b. Implement interventions from low /moderate risk protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: I. Assistive devices ii. Increased frequency of round iii. Sitter if indicated. iv. Medication regimen review v. Low bed 676221 Page 12 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0689 vi. Alternate call system Level of Harm - Immediate jeopardy to resident health or safety vii. Scheduled ambulation or toileting assistance. Residents Affected - Few ix. Therapy services referral viii. Family/caregiver or resident education This was determined to be an Immediate Jeopardy (IJ) on 09/24/23 at 2:00 PM. The DON, was notified. The DON was provided the Immediate Jeopardy template on 09/24/23 via email at 2:00 PM. The following Plan of Removal was submitted and accepted on 09/26/23 at 4:32 AM. Plan of Removal Immediate action: On 9/26/23 an audit of Fall Risk Assessment was completed. Any resident who was identify as being at high risk for falls was falls was assessed and their care plan reviewed to ensure current interventions were appropriate. There were 19 total residents identified, no other residents were affected. Facilities Plan to Ensure Compliance: What does the facility need to change immediately to keep residents safe and ensure it does not happen again? What corrective actions have been implemented for the identified residents? The following action items were implemented immediately on 9/26/23. An in-service was initiated with licensed nurses on 09/26/23, by the Director of Nurse FOR REMOVAL OF IMMEDIATE JEOPARDY On September 5th, 2023, an annual survey was initiated at. On September 24th, 2023, at approximately 1:00 pm, the facility was notified by the surveyor that an immediate jeopardy had been called and needed to submit a letter of credible allegation. The Facility respectfully submits this Letter of Credible Allegation pursuant to Federal and State regulatory requirements. Issue: F-Tag 689: Facility failed to ensure resident #50 had adequate supervision and assistive devices to prevent an accident on 07/25/23. The facility failed to accurately assess Resident # 50 risk for falls and assistive devices. The facility failed to update fall precaution interventions after severe falls. Done for those affected: On 09/24/2023 a new fall risk assessment was performed on resident #50 by DON, MDS Nurse and Rehabilitation Director. Completed on 9/24/23 and was reviewed surveyor. On 09/24/2023 PCP and medical director were notified of current interventions in place to minimize injuries and agreed with interventions. Completed on 9/24/23 676221 Page 13 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 09/24/2023 RP was notified of current interventions in place to minimize injuries and agreed with interventions. Completed on 9/24/23 On 09/24/2023 Head to toe assessment completed Resident # 50 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 09/24/2023. On 09/24/2023, other residents identified with frequent falls were reviewed for appropriate assistive devices, interventions, and fall risk . Completed on 09/24/2023. These was review by the surveyors. On 09/24/2023 all other residents care plans were reviewed for appropriate assistive devices and fall risk. Completed on 9/24/23 On 09/24/2023 all nurses and nursing staff present in the facility were in-serviced on facility fall risk assessment, care planning, implementing interventions, and on the use of assistive devices. Staff not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed for that individual. On 09/24/2023 all staff at the facility were in-serviced on current interventions and assistive devices for resident #50 either in person or by phone. Staff not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed for that individual. Identify residents who could be affected: On 09/24/2023 Administrator and/or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified to be affected by the same deficient practice. Completed on 9/24/23. Action Taken: On 09/24/2023 resident # 50 was assessed for appropriate assistive devices and adequate type of supervision to minimize the risk for falls and injuries. Care plan immediately updated to reflect new assessment including appropriate use of assistive devices and interventions. On 09/24/2023 All nurse managers were educated on ensuring resident care plans are updated after falls to include appropriate interventions and assistive devices, where applicable, either in person or by phone. Effective immediately (after care plan updated) on 09/24/2023, the Administrator / DON and/or designee began re-education to all staff on the facility fall risk assessment, care planning, implementing interventions, and on the use of assistive devices for resident # 50. Staff present in the facility on 09/24/2023 were in-serviced on 09/24/2023. Staff not present in the facility on 09/24/2023 will not be allowed to provide direct care until training has been completed. Those that are not scheduled to work on 09/24/2023 will have the re-education completed prior to the start of their next scheduled shift. Phone calls conducted for those not currently working. On 09/24/2023, the Administrator, DON and Director of Rehabilitation Services provided one to one re-education to all LVNs, RNs and nurse managers on adequate supervision, assistive devices, fall 676221 Page 14 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few precautions, person-centered care planning with measurable objectives and timeframe, and adequate interventions. Education was completed on 09/25/2023. Surveyor Monitored the plan of removal and interview as follows: The Administrator, DON, ADON and Rehab Director will conduct random weekly checks, on all shifts, on the high risk fall residents or any new admits implementing timely interventions post fall, physician notification, neglect and implementing timely fall interventions post fall, and updating the care plan timely with interventions to prevent falls by 9/26/23. Any direct care staff member not in-serviced by 9/27/23 will not be allowed to work until the in-servicing is completed. For the next 30 days the DON and ADON will monitor the nursing staff per week o given to determine retention of knowledge the universal fall precaution protocol. The results of these audits will be reviewed in the Quality Assurance and Performance Improvement meeting monthly for 6 months or until 100% compliance is achieved x3 consecutive months. The QAPI Committee will continue to monitor monthly to identify any trends or patterns and make recommendations to revise the plan of correction as indicated. Observations were started on 09/24/23 at different times, 3:00 PM, 4:00PM, 09/25/23, 8:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM, 09/26/23, 9:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 5:00 PM, 09/27/23 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 6:00 PM, 7:30 PM, 09/28/23, 9:40 AM, 10:30 AM, 11:40 AM, 1:30 PM, 3:45 PM, 6:00 PM, 09/29/23, 12:40 PM, 1:30 PM, 3:45 PM, 5:00 PM and continued through 09/30/23, 10:30 AM, 11:30 AM, and 12:30 PM, 1:30PM. Observations were started on 09/24/23 and continued through 09/30/23. Observation of Resident ( #19, #50, #62, #84 ) revealed bedrooms were free of clutter and adaptive devices were available for residents at risk for falls. Interviews were conducted on 09/24/23, 09/25/23, 09/26/23, 09/27/23, 09/28/23, 09/29/23 , 09/30/23 with over 20 staffs across all 6:00 AM to 6:00PM and 6:00PM to 6:00 AM shifts, including weekdays, weekends, and multiple departments. The staff interviewed regarding the plan of removal: Administrator, DON, ADON, MDS RN, CNA A, CNA B, CNA C, C.NA D LVN A, LVN B, LVN C, LVNC, LVN D, MA A, CNA D, CNA E, CNA F, CNA G, PT, OTA and RN A. All staff interviewed verbalized adequate understanding of plan of remove training received including Universal Fall Precautions policy/procedures, star program , [NAME] system, and Fall Prevention Procedures. Record review of the facility POR Binder revealed: Over 25 staffs were in-serviced on 09/26/23, 09/27/23 and 09/28/23 regarding Fall Interventions and Intervention for high - Risk Fall. Universal Fall Precautions policy/procedure. Timely interventions Post Falls. Reporting, incidents, [NAME] system and Fall Prevention Procedures. Immediately notify DON and /or Administrator. Reporting Abuse and neglect, Neglect and Resident's Rights. During an interview on 09/26/2023 at 1:59p.m. with DON,RN said, she believed the facility currently has an IJ because of the resident's history of falls. She said the resident did not need a 1 on1 supervision, but because he had so many falls, it was a concern. She said there were no high risk falls care plan and she now have a system in place to identify high risk for falls residents ( the Star program) to have nursing staffs monitored residents closely and document each falls. 676221 Page 15 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During interview with the Administrator on 9/26/23 at 2:30 PM He stated that he had been an administrator for 20 some years. He Understood that the facility has an IJ because the facility did not report the incident to the State thus the facility did not investigate the incident. In investigating the incident, the facility will be able to ensure that abuse did not occur, and fall will not occur with injuries, having plan/ process in place by identifying the root cause of the fall. During an interview on 09/26/2023 at 2:32p.m. the Administrator said, he believes the facility is currently has an IJ because there was a resident that fell and sustained a major injury. He said he has made sure that everybody understands how important it is to supervise residents. He said a big part of the morning meetings and meeting with quality assurance, is to make sure high-risk residents are always monitored. He said if there is a change in the environment, staff should know those changes and adapt to those changes. He said it is hard to do your job if you do not understand how to do certain things. He said he knows how staff is interacting with the residents by monitoring, walking around and observing what is happening on the floor and educating them with in-service trainings and the use of assistive device to prevent fall and minimized injury. During an interview on 09/26/2023 at 1:33p.m. the ADON, LVN said, she doesn't know why the facility has an IJ. She said she knew the incident that happened with the resident and that he had a fall. She said she was not working the day the resident had the fall. She said she could improve her work by being thorough with her documentation. She said all staff need to always monitor the residents at the facility. She said the high fall risk residents she be around the nurse's station so that someone can keep a close eye on the residents. She said things would have gone differently if she was present at work during the incident with the resident. She said would have put interventions in place and care planned the falls based on how the falls happened. She said some of the trainings for staff are ongoing. She said she had a broad view on how to care for the residents. She said the purpose of having in-service training is so that staff understands how to take care of the residents. She said things change and staff must continue to receive training to adapt to those changes and star fall program. During an interview on 09/28/2023 at 1:42 p.m. with MDS RN, RN said the facility has an IJ because there was a resident with frequent falls, and they did not put assistive device to prevent him for falling and it resulted in a major injury. He said they went back and reviewed what was going on with the resident. He said for now on he is going to pay closer attention to the residents that are high risk for falls. He said the care plans will be closely directed to the resident. He said he will work closer with the nursing staffs and document to show that the residents are being monitored. He said the care plans was not being done correctly since he has been at the facility. He said the care plans needs to be individualized on falls. The Administrator was informed the Immediate Jeopardy was removed on 09/28/23 at 9:46 AM. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. 676221 Page 16 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 dialysis service was provided consistently with professional standards of practice for 1 of 3 residents (Residents #72) reviewed for dialysis services. Residents Affected - Few The facility failed to keep ongoing communication with the dialysis facility for Resident #72. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #72's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] was readmitted on [DATE] . Her diagnoses included fluid overload, retention of urine, dependence on dialysis, muscle wasting and atrophy and abnormalities of gait and mobility. Record review of Resident #72's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Record review of Resident #72's care plan undated revealed the resident has diagnosis of renal failure and received dialysis. Goal and innervations were outlined. Intervention did not address maintaining an on-going communication with the dialysis facility for Resident #72. Record review of Resident #72's progress notes dated 08/28/2023 revealed the resident had end stage renal disease, required dialysis Monday, Wednesday, and Friday. Interview on 09/05/2022 at 9:48am revealed Resident #72 was in his bed in his room. He was alert, oriented X3 and was able to make needs known. Resident stated he had been going to dialysis since 07/03/2023. Resident stated his dialysis days were Monday, Wednesday, and Friday. When asked if facility staff gave him a communication paper or form for his dialysis, resident said no. When asked if his dialysis facility provided a form of communication form/paper that contained summary of how his daily dialysis went, the resident said, he had never received anything like that from both facilities. Interview on 09/08/2022 about 03:32 p.m., the DON said was asked how the facility. DON said she did not think the facility has maintained ongoing communication with the dialysis facility for Resident #72. The DON stated staff should have been providing a form of communication to resident to take to his dialysis facility and should return with one. Interview on 09/08/2022 at 05:58 p.m., the DON said she looked further into the dialysis communication form requested. She was told facility staff gave the resident a communication form when leaving for dialysis, but the resident did not return with them. When asked if the facility reached out to the dialysis facility and inquired why the communication forms were not given to the resident at the end of his dialysis, DON said she wasn't sure facility had not done that. Record review of nursing home transfer agreement provided by the facility dated November 2014 revealed in providing dialysis treatments to designated residents, center shall adhere to the requirement of applicable state and federal law and regulations and shall maintain policies and procedure that provide for quality patient care, infection control, emergency care, proper waste handling, 676221 Page 17 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0698 maintaining of equipment, water treatment, patient record keeping and patient safety. Level of Harm - Minimal harm or potential for actual harm Record review of facility's dialysis resident policy revised 01/2022 did not address communication strategies between dialysis center and the facility. Residents Affected - Few 676221 Page 18 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 8 (Resident #32) reviewed for medication administration. The facility failed to ensure that LVN A did not administered Resident #4's Prednisolone Acetate Ophthalmic (eye drop medication used to treat inflammation of the eyes) to Resident #32. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Resident #32 Record Review of Resident #32 electronic face sheet dated 09/08/23 revealed a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #32 had the diagnosis of inflammation of the eyes. Record Review of Resident #32 Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 10, which indicated Resident #32's cognition was moderately impaired. The MDS reflected Resident #32 required a scheduled eye medication regimen. Record review of Resident #32's physician orders revealed an order dated 09/03/2020 at 09:00a.m., Prednisolone Acetate ophthalmic 1% 1 drop in right eye one time a day for 7 days then stop 09/10/23. Record Review of Resident #32's MAR, dated September 2023, revealed she was scheduled to receive the following: Prednisolone Acetate ophthalmic 1% 1 drop in right eye one time a day for 7 days then stop 09/10/23 at 09:00 am. Further review of the MAR revealed there were check marks or initials by these medications, which indicated they had been administered. Observation and interview on 9/6/23 at 8:11 AM during medication administration, LVN B used Resident #4's Prednisone Acetate 1% 1 drop to Resident #32's eye right. LVN B was shown the name on the medication bottle and room number, LVN B said the eye bottle was placed in Resident #32's box, she did know it was another resident medication. In an interview on 09/06/23 at 9:58 AM, LVN B stated she will be more careful by checking the medications multiple times before administration. LVN B said not checking the medications could result in errors. An interview with the DON on 9/8/23 at 03:15 PM revealed it was important to administer right medications to the right resident,. The DON stated the medications could lose their potency or cause an unexpected reaction and she was going to do in-services. Review of the facility's Policy's titled Administrating Medications, revised April 2019 read in 676221 Page 19 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0755 Level of Harm - Minimal harm or potential for actual harm part: Policy statement: Medications are administered in a safe and timely manner, and as prescribed 4. Medications are administered in accordance with prescriber order, including any required time frame 10. The individual administering the medication checks the label THREE(3) times to verify the right resident, right medication, right dosage, right time .before giving the medication . Residents Affected - Few 676221 Page 20 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable when applicable for 2 of 4 medication Carts reviewed for medication storage. The facility failed to ensure the medication (med) chart 100-hall did not have the expired medications Packets of Arginaid ( Arginne powder) ( used to help support the unique nutritional needs of individuals with wounds). The facility failed to ensure the Nurses medication carts 300-hall did not have the opened and undated medications: *Alphagan Brimonidine tartrate ophthalmic solution 0.1% ( used for an alpha adrenergic receptor agonist of indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension). *Prednisolone Acetate ophthalmic suspension 1 vial for ( drug used to treat inflammation of the eyes caused by certain condition), and *Fluticasone Propionate Nasal spray 50 mcg for 1 spray in each Nostril daily ( used to treat sneezing, itchy or runny nose or other symptoms caused by hay fever and chronic rhinosinusitis). These failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings include: 300 Hall Nursing Cart Observation of 300 hall nurses' medication cart with LVN ADON on 9/7/23 at 2:22 PM revealed the following medications were opened and undated 1.Alphagan Brimonidine tartrate ophthalmic solution 0.1% 1 bottle. 2. Prednisolone Acetate ophthalmic suspension 1 bottle. 3. Fluticasone Propionate Nasal spray 50 mcg for 1 spray in each Nostril daily Interview with ADON on 9/7/23 at 2:22 PM she said those medications should be dated when opened. 100 Hall MA Cart Observation of 100 hall medication cart with MA A on 9/7/23 at 3:09 PM , Revealed there were 11 packets of Arginaid in the original container, had expired 20 August 2023. 676221 Page 21 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with MA A on 9/7/23 at 3:30 PM she stated she checked her medication cart for expired medication on a daily basis and said Arginaid box was just open last week. Interview with the ADON on 09/07/23 at 4:00 PM, the ADON said she, the MA's and the charge nurses were supposed to check the medication cart for expired medications every daily and any open eye drops bottle and suspended medications should have open date. The ADON said her expectation was to not have any expired medications in the med cart and expired medications would not produce desire result. In an interview with the DON on 9/8/23 at 11:03 AM revealed her expectation was for the nurses to return . She would have the ADON audit the medication cart more frequently instead of monthly. The DON stated giving residents expired medications could change chemical composition of the drugs over time which and could be rendered unsafe or ineffective. An interview with the DON on 9/8/23 at 03:15 PM revealed it was important not to administer expired medications because the expiration dates were there for a reason. The DON stated the medications could lose their potency or cause an unexpected reaction because their chemical makeup could be altered after the expiration dates. According to the FDA website accessed on (date) at (website) revealed , drug expiration dates reflect the time period during which the product is known to remain stable, which means it retains its strength, quality, and purity when it is stored according to its labeled storage conditions. If a drug has degraded, it might not provide the patient with the intended benefit because it has a lower strength than intended. In addition, when a drug degrades it may yield toxic compounds that could cause consumers to experience unintended side effects. 676221 Page 22 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an adequately furnished space for dining and activities for 1 of 1 dining room and 1 of 1 activity room reviewed for dining and activity rooms. The facility did not provide an adequately furnished dining room or activity room for dining and resident activities. This failure could place the residents at risk for psychosocial harm and decreased quality of life. Findings included: Record review of the face sheet indicated Resident #55 was a [AGE] year-old male and was admitted on [DATE] with diagnoses including dementia, behavior disturbance, psychotic disturbance, mood disturbance anxiety and muscle wasting and atrophy (thinning or loss of muscle tissue). Record review of the MDS dated [DATE] indicated Resident #55 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated he was moderately cognitively impaired. The MDS indicated Resident #12 needed supervision and 1-person physical assist for all activities of daily living. Observation and interview with Resident #55 on 9/7/2023 at 11:54a.m., revealed him coming out of the restroom inside of his room. He said the facility needs chairs in the dining room. He said those who are wheelchair accessible use their wheelchair as a chair. He said residents without wheelchairs need a chair. He said he must bring chairs from one place to another. He said this is unheard of. He said he has told staff and the Administrator multiple times about the lack of chairs in the dining room. Observation on 9/7/2023 at 11:57a.m., revealed two chairs to a table in the dining room area. There are three tables without chairs. Majority of the residents in the dining room area, are at the table sitting in their wheelchairs. There weren't many chairs available. Observation and interview on 9/7/2023 at 12:03p.m., revealed Resident #55 sitting at a dining room table with two female residents. Both women at the table were using their walker as a chair. Resident #8 said he grabbed his chair from the activity room. Observation on 9/7/2023 at 12:04p.m., revealed a male resident carrying a chair to a table in the dining room area. During Resident Council on 09/06/2023 at 10:59a.m., Resident #55 said there was not enough chairs for seating in the dining room area when the meals are being served. He said he has to carry a chair in from the activity's room or other areas of the facility. He said he has to get in the dining hall early, to ensure he gets a place at the table. He said they were supposed to be ordering more chairs, but it has been a while and he has yet to see new chairs. He said the facility had brought some tables, but no chairs. Resident #55 was observed a chair from the activity's room out to the dining area. He did not want help carrying the chair, he said it helps keep him strong. 676221 Page 23 of 24 676221 09/30/2023 Heritage Park of Katy Nursing and Rehabilitation 6001 George Bush Dr Katy, TX 77493

F 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 9/6/2023 at 5:38p.m. at the end day conference with Administrator, said they ordered new tables and chairs. He said the chairs were custom made chairs. He said the tables have already arrived and been put together. He said the chairs are taking longer because they are custom made and it is difficult to ship. He said he does not know how much longer it will be before the chairs arrive. He said residents have enough places to sit. He said sometimes staff bring chairs from other areas. He said residents should not have to bring their own chairs, staff will bring in the chair from other areas if they need to, and help residents carry the chairs. Record Review of the facility's policy on dining was not provided by the facility. 676221 Page 24 of 24