Health inspection·September 27, 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 ensure that all alleged violations involving injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 of 5 residents (Residents #1) reviewed for abuse and neglect, in that: The facility failed to report Resident #1's unwitnessed fall resulting in a fracture requiring hospitalization to the state agency within required time frames. This deficient practice could place residents at risk for not having injuries of unknown origin reported to the State Agency to ensure that allegations are fully investigated. Findings included: Record review of the Assessment form after an incident written by the nurse of Resident #1's fall dated 09/19/23 at 7:15 am revealed that nursing noted resident sitting on the floor upright with her back against the bed. Resident is alert and oriented. Resident's right femur appears misaligned, resident had skin tear to right arm with heavy swelling and mild bleeding. Resident had some bruising to the right temple, no swelling or active bleeding noted at this time. Record review of the Assessment form after an incident written by the nurse of Resident #1's description of the fall dated 09/19//23 at 7:15 am revealed that she was trying to use the bathroom, then slipped and fell backwards. Roommate stated resident fell coming from the restroom. Resident #1 stated that she doesn't remember anything after she fell. Record review of the Assessment form after an incident written by nurse of Resident #1's fall dated 09/19/23 at 7:15 am revealed Immediate action taken: Resident had some blood to left temple. Nurse did not move Resident #1 and activated EMS. Resident taken to the hospital. Nurse was unable to determine injury type; but nurse observed front right thigh injury location, level pain of 6, level of consciousness alert, mental status - oriented to person, to situation, and to place. Predisposing physiological factor: weakness/fainted. No witness found. Record review of Resident #1's care plan dated 07/07/23 revealed that Resident #1 requires assistance with her ADL's. She recently fell and had a left hip fracture. She does require more assistance (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676252 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 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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)