Health inspection·September 29, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review the facility failed to implement their written policies and procedures for reporting all allegations involving abuse, neglect and injuries of an unknown source in accordance with the state law for 1 of 8 residents (Resident #61) reviewed for abuse and neglect. The facility did not provide the state agency with a provider investigation report within 5 working days. This failure could place residents at risk of injury abuse and neglect. Findings included: A face sheet dated 09/23/2023 indicated Resident #61 was [AGE] years old admitted on [DATE] with diagnosis that included but not limited to the following: Anxiety, type 2 diabetes (high blood sugar levels), muscle wasting and atrophy to multiple sites, hypertension (high blood pressure), insomnia and depression. A MDS dated [DATE] indicated Resident #61 had moderate cognitive impairment. A care plan dated 08/20/23 revealed Resident #61 was at risk for skin injury, new or worsening skin condition; thin, fragile, loose skin-09/11/2023: dog bite top of right hand. A Progress note with an effective date of 09/11/2023 revealed Resident #61, was walking down 100 hallway. A dog bit her rt hand, skin tear size of a quarter. Minimal bleeding cleaned with antiseptic and dressed in Antibiotic ointment. Dog owner is emailing shot records. Said he had all his shots. Contacted Doctor, new order for antibiotic. See new orders. Will monitor for infection, dressing change daily. A subsequent progress note, in Resident #61's electronic health record, with an effective date of 09/11/2023 revealed the patient complained of pain in right hand, the Doctor was contacted and T3 1-2 tabs Q6hours PRN for pain not to exceed 4g in 24-hour period. During an interview on 09/28/2023 at 1:31 p.m. Resident #61 said, my hand hurts and it is messy. Resident #61 went on to say she was bitten on the hand by a dog someone brought into the facility. Resident #61 further stated she asked the owner of the dog if the dog bit and if she could pet him. Resident #61 reported the dog owner told her the dog did not bite and she could pet him. Resident #61 said, I don't think anyone that has a dog that bites should ever bring one into a facility like this, Page 1 of 6 676224 676224 09/29/2023 The Heights on Huebner 10127 Huebner Rd San Antonio, TX 78240

F 0609 they just should not. She stated if a dog came up to her now, she would shy away and get away. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/28/2023 at 3:25 p.m. the DON stated the dog bite was not reported to the State of Texas through TULIP because the facility did not believe it should be reported and considered it an incident. Residents Affected - Few During an interview on 09/29/2023 at 1:58 p.m. the Administrator stated the dog bite was not reported to the State of Texas through TULIP because the facility considered the event an incident. A policy regarding pets being brought into the facility by visitors was requested. The Administrator stated the facility did not have a facility policy regarding animals being brought into the facility by visitors. The Administrator explained the facility had practice of asking for vaccination records prior to allowing any animals into the facility resident care area. She was not at the facility the day of the incident and did not know who allowed the dog into the resident care area or why the dog's vaccinations records were not requested prior to entry. She reported vaccination records indicated the dog was a mixed breed dog that weighed 80 to 85 pounds. 676224 Page 2 of 6 676224 09/29/2023 The Heights on Huebner 10127 Huebner Rd San Antonio, TX 78240

F 0610 Respond appropriately to all alleged violations. 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 thoroughly investigate an allegation of abuse for 1 of 1 resident (Resident #61) reviewed for abuse and neglect. Residents Affected - Few The facility did not thoroughly investigate when Resident #61 was bitten by a visitors dog. This failure could place residents at risk for allegations of abuse or neglect not being thoroughly investigated by the facility and reported as required. Findings include: A face sheet dated 09/23/2023 indicated Resident #61 was [AGE] years old admitted on [DATE] with diagnosis that included but not limited to the following: Anxiety, type 2 diabetes (high blood sugar levels), muscle wasting and atrophy to multiple sites, hypertension (high blood pressure), insomnia and depression. A MDS dated [DATE] indicated Resident #61 had moderate cognitive impairment. A care plan dated 08/20/23 revealed Resident #61 was at risk for skin injury, new or worsening skin condition; thin, fragile, loose skin-09/11/2023: dog bite top of right hand. During an interview on 09/28/2023 at 1:31 p.m. the Resident said, my hand hurts and it is messy. Resident #61 went on to say she was bitten on the hand by a dog someone brought into the facility. Resident #61 further stated she asked the owner of the dog if the dog bit and if she could pet him. Resident #61 reported the dog owner told her the dog did not bite and she could pet him. Resident #61 said, I don't think anyone that has a dog that bites should ever bring one into a facility like this, they just should not. Resident #61 stated if a dog came up to her now, she would shy away and get away. During an interview on 09/28/2023 at 3:25 p.m. the DON stated the dog bite was not reported to the State of Texas through TULIP because the facility did not believe it should be reported and considered it an incident. The DON stated Resident #61's incident was not investigated. The DON said the incident did not need to be investigated, it was not abuse or neglect, it was an incident. During an interview on 09/29/2023 at 1:58 p.m. the Administrator stated the dog bite was not reported to the State of Texas through TULIP because the facility considered the event an incident and the incident was not investigated and explained the facility did not consider the dog bite abuse or neglect. A policy regarding pets being brought into by the facility was requested. The Administrator stated the facility did not have a facility policy regarding animals being brought into the facility by visitors. The Administrator explained the facility had a practice of asking for vaccination records prior to allowing any animals into the facility resident care area. She was not at the facility the day of the incident and did not who allowed the dog into the resident care area or did not know why the dog's vaccinations records were not requested prior to entry. She further stated, she did not investigate the incident, as it did not meet the reporting guidelines of the Long Term Care Regulatory Provider Letter Number: PL 19-17, Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the 676224 Page 3 of 6 676224 09/29/2023 The Heights on Huebner 10127 Huebner Rd San Antonio, TX 78240

F 0610 Level of Harm - Minimal harm or potential for actual harm Review of Provider Letter 19-17, dated 7/10/2019, revealed neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury should be reported immediately, but not later than two hours after the incident occurs or is suspected. Residents Affected - Few 676224 Page 4 of 6 676224 09/29/2023 The Heights on Huebner 10127 Huebner Rd San Antonio, TX 78240

F 0656 Level of Harm - Minimal harm or potential for actual harm 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 complete a comprehensive assessment of 1 of 24 residents (Resident # 78) reviewed for comprehensive person-centered care plans in that The facility failed to do a comprehensive assessment for Resident #78 that included a preference to receive medications in the dining room. This deficient practice could place residents at risk of receiving inadequate assessments not individualized to their care needs. The findings included: Record review of Resident # 78's face sheet dated 9/28/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: [Dementia] is a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life. [Conductive Hearing Loss] Hearing loss is caused by something that stops sounds from getting through the outer or middle ear. [Unspecified Pain] Physical suffering or discomfort caused by illness or injury Record review of Resident # 78's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating intact cognition. Record review of Resident # 78's care plans dated 9/28/23 did not reveal any care plan regarding the resident's preference to receive medications in the dining room. Record review of Resident # 78's Physician orders, dated 9/28/23, did not reveal any physician orders to administer medication with food. Observation and interview on 9/28/23 at 8:45 a.m., Medication aide F administered morning medication to Resident # 78 in the dining room. Medication aide F stated Resident # 78 preferred her medication in the dining room along with her meals. Medication aide F stated she did not have a doctor's order to give medications with a meal but would inform the DON. Medication aide F stated by giving medications to Resident # 78 in the dining room along with food, Resident # 78 risked possibly less absorption of a medication. Interview with Resident # 78 on 9/28/23 at 9:00 a.m. stated she preferred all her medication in the dining room along with her meal, because if she takes medication on an empty stomach, she gets nauseous. Interview on 9/28/23 at 9:15 a.m., MDS Nurse A stated she was assigned care plans for long-term care residents to include Resident # 78. MDS Nurse A stated she was unaware that Resident # 78 preferred her medication in the dining room. MDS Nurse A stated she reviewed all long-term residents' care plans quarterly following an interdisciplinary team approach. She stated she does not know why Resident # 78's preference to have received medications in the dining room was not reflected in the care plan, but she would update it. MDS Nurse A stated if the care plan does not indicate Resident # 78's preference to receive medication in the dining room, the nursing staff risked not being on the same 676224 Page 5 of 6 676224 09/29/2023 The Heights on Huebner 10127 Huebner Rd San Antonio, TX 78240

F 0656 page regarding Resident # 78's preferences. Level of Harm - Minimal harm or potential for actual harm In an interview on 8/28/23 at 10:35 a.m., the DON stated the care plan had not been revised to include the preference for Resident # 78 to receive medications in the dining room. The DON revealed the interdisciplinary team updated care plans quarterly. She further revealed the entire nursing leadership team was responsible for updating care plans; she was unsure how the update to the care plan was missed. The DON stated by not revising care plans, staff risked not being on the same page regarding resident care. Residents Affected - Few Record review of the facility policy, Care Plans: February 2017, revealed The care plan will describe the services to be furnished to attain or maintain the highest practicable physical, mental, and psychological well-being. 676224 Page 6 of 6