Health inspection·December 8, 2023

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 observation, interview and record review, the facility failed to ensure 1 of 2 residents reviewed for ADL care (Resident #62) who was unable to carry out activities of daily living was provided services to maintain good nutrition, for 1 of 2 residents (Resident #62) reviewed for ADL care in that: Residents Affected - Some - Resident #62 missed 2 out of 4 meals observed due to staff not assisting her with feeding. This failure placed residents in need of ADL assistance at risk of malnutrition and malnourishment. Findings included: Record review of Resident #62's face sheet , dated 12/07/2023, reflected an [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with encephalopathy (change in brain function), anemia, acute kidney failure, type 2 diabetes mellitus with diabetic chronic kidney disease, muscle wasting and atrophy, and need for assistance with personal care. Record review of Resident #62's MDS, dated [DATE], reflected the resident's BIMS score was an eight, indicating the resident's cognition was moderately impaired. It also revealed the resident needed extensive assistance with eating, requiring one-person assistance with meals. Record review of Resident #62's care plan, dated 09/25/2023, reflected Resident #62 required assistance with all ADLs due to poor cognition with interventions including giving verbal cues to help prompt the resident. Record review of Resident #62's MAR, dated December 2023, revealed Regular diet Regular texture, Regular consistency, Thin Liquids, chopped meat. Add fortified foods and large portions at all meals for Diabetic/GERD Diet. Record review of Resident #62's progress notes, dated 11/10/2023, revealed the RD assessed Resident #62 and noted the her diet consisted of, . Snacks supplements: 1 house shake BID (400cals, 12g pro), liquid protein 60mL BID (400cals, 60g pro) resident was ordered a regular, chopped diet with thin liquids. Observation of Resident #62 on 12/06/2023 at 10:04AM, revealed the resident was in bed tilted towards her left side with the right side of her head pressed up against the bed rail. The resident was yelling out help me. The resident stated her head hurt and nobody had come to help her. She stated she was trying to eat but then she fell asleep and woke up like this but could not get up. The meal Page 1 of 10 676252 676252 12/08/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tray was observed in front of the resident with and her food, which consisted of eggs and chopped sausages, untouched. She stated she no longer had the desire to eat. She stated everything in the facility was good but herself because of her pain and because she could not pick her food up. She stated she had been waiting on her mother and father to come help her, but no one had come. She stated she has been trying to eat but felt like she had trouble feeding herself for the past 2-3 weeks. At 10:08 AM the surveyor called for assistance and CNA L came to help reposition the resident. In observations and an interview with CNA L on 12/06/2023, she stated Resident #62 was able to feed herself and just needed help set up . She stated the resident was sleeping when she first dropped off her tray, so she left it for her. She said she tried to wake the resident up, but she didn't wake. She stated she believed the resident ended up stuck in the position she was found in because she might have woken up and attempted to feed herself. She stated Resident #62 was prone to leaning to the right. CNA L was observed to take Resident #62's tray without offering Resident #62 any alternative to the missed meal. Record review of Resident #62's point of care response history for amount of meal eaten, revealed on 12/06/23 at 7AM, the resident was marked by CNA L to have eaten 51-75% of her breakfast meal and on 12/07/2023 1:21AM, the resident was marked to have eaten 51-75%. In an interview with a family member on 12/06/2023 at 12:55PM, the family member stated they believed that Resident #62 needed assistance with feeing be she could barely feed herself because she often complained of pain in her legs and could not sit up straight. In an interview with LVN D on 12/06/2023 at 4:15PM, he stated CNA L reported to him the position Resident #62 was found in earlier today. He stated Resident #62 was generally unable to reposition herself but could slide around in the bed. He also stated the resident was capable of feeding herself with set up help . Observation of Resident #62 on 12/07/2023 at 1:21PM revealed the resident lying in bed asleep with her meal tray at bedside. Her meal and drinks were still sealed/covered and untouched . Observations and an interview with Resident #62 on 12/07/2023 at 1:42PM, revealed the resident lying asleep in bed with her meal tray gone. Resident #62 stated she did not eat lunch, and no one told her what it was. When the surveyor told her it was barbecue chicken and potato salad, she stated, Don't throw it away, I can't eat it later . In an interview with CNA L on 12/07/2023 at 1:55PM, she stated she did not pick up Resident #62's tray, neither did she know who did, because she was not available at the time. In an interview with CNA B on 12/07/2023 at 1:57PM, she stated she picked up Resident #62's tray after lunch. She stated she asked the resident if she wanted to eat and the resident responded no, so she took her tray away. When asked if she knew is the resident needed assistance with feeding or not, she stated she was not sure because she did not work with Resident #62 often but believed the resident was able to feed herself . Observation of the meal cart on 12/07/2023 at 1:52PM revealed Resident #62's meal was stored back on to the cart and brought back to the kitchen to be thrown away with the meal still sealed covered and untouched. 676252 Page 2 of 10 676252 12/08/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #62's point of care response history for amount of meal eaten, revealed on 12/06/23 at 7AM, resident was marked by CNA L to have eaten 51-75% of her breakfast meal and on 12/07/2023 1:21AM, the resident was marked to have eaten 51-75%. Record review of Resident #62's point of care response history for ADL level for eating, revealed on 12/06/23 at 7AM and on 12/07/2023 1:21AM, the resident was marked by CNA L to only need supervision for her meals. In a phone interview with CNA L on 12/07/23 at 02:11 PM, she stated Resident #62 would only need set up help for the most part. She stated she believed she would not have eaten as much if she was not there to assist her. She stated the resident needed to be spoon fed at times while sometimes she more hands on and able to pick up food with her hands and feed herself. She stated she knew how much assistance was needed for meals by either asking nursing staff or asking the residents themselves, and if they were not responsive or verbal, she would try to feed them and see if they showed interest in eating. CNA L confirmed that Resident #62 did not eat her breakfast on 12/06/2023 and she was not sure how much the resident ate for lunch on 12/07/2023 because she did not pick up her tray. When asked why she documented at least 50% for the amount eaten, she stated she did not remember documenting that. CNA L stated she did not report to the nurse when Resident #62 did not eat any of her meals although, it was important to report to the nurse if meals were skipped because it could affect their health and nutrition. In an interview with LVN D at 12/07/23 04:02 PM, he stated if Resident #62 was propped sitting up and was given a spoon, she could feed herself, but the CNAs for the most part assisted her with eating by spoon feeding her. LVN D stated he believed the level of supervision for eating was correct for Resident #62 because she could physically feed herself, but without assistance she was not inclined to eat much or at all so the CNAs went in and assisted her so she could eat an adequate amount. LVN D stated CNAs typically would ask Resident #62 if she wanted to eat, but if she said no, they just take the tray and move onto the next person. He stated CNA L was supposed to offer Resident #62 house shakes and incorrectly documenting the percentage of a meal eaten on the point of care history was not acceptable. He stated the expectation for the aides was to verbally tell him if the resident was refusing the meal or was eating less than 50% and CNA L never reported that to him about Resident #62. He stated in terms of determining the level of assistance needed for residents for eating, he did not refer to the care plan , but instead made his own personal patient assessment of the resident to know the resident's ADL level for eating or found out from other aides. He stated the risks of not communicating missed meals could be a decline in health, and nutrition, weight loss, bad disposition, and not enough protein to prevent wound healing. In an interview with the DON on 12/07/2023 at 5:30PM, she stated she was talking with the Dietitian after they discovered Resident #62 recently experienced a weight loss within the last month. She stated the resident needed interventions placed, including assistance with feeding . Record review of Resident #62's progress notes, dated 12/07/2023, revealed DON wrote, . RP and resident informed that residents current weight is 162 pounds. Residents po intake has decreased even though residents family on occasion will bring food preferences and home cooked meals in to help with intake. RP comes to visit resident in the evening and stated she has noticed residents intake has decreased over the last two weeks. Will continue to honor resident preferences, assist with all meals and offer supplements as needed. MD and RD notified. Will continue plan of care . Record review of Resident #62's MAR, dated December of 2023, revealed the resident was marked off 676252 Page 3 of 10 676252 12/08/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0677 daily for having received snacks twice a day by CMA A. Level of Harm - Minimal harm or potential for actual harm In an interview with CMA A on 12/08/2023 at 9:10AM, she stated she did not give Resident #62 snacks during med pass. She stated during her lunch breaks, if she remembered to, sometimes she would give snacks to people. She stated she never gave Resident #62 her morning snack because it was ordered for 10AM, which is right after their breakfast time. When asked why she still documented snacks as given twice a day when she never gave morning snacks and only gave an afternoon snack sometimes, she stated, I already answered you. You know how it is. Residents Affected - Some In an interview with the DON on 12/08/23 at 01:34 PM, she stated during mealtime she expected CNAs to set up meal trays, assist with feeding or cueing as needed, for the residents who needed it. She said if resident's intake was not adequate, or below <50%, CNAs needed to report it to their charge nurse so they could go back and note the reason for their decreased intake. She stated she expected for documentation by aides of percentage of meal eaten to be accurate and for the follow up notes to be written by the charge nurse showing he was aware of meals eaten <50%. The DON said that snacks should not be on the MAR but the nurse needed to be offering residents a snacks to encourage intake. She said all aides and nurses should have referred to the EMR or care plan to find out the level of assistance each resident needed for feeding. She stated all those measures should have been in place to maintain consistency and ongoing communication about Resident #62's care and to put measures in place in a timely manner to prevent weight loss or deterioration. She also stated Resident #62 needed assistance with feeding because she was not consistent with self-feeding because her drive had gone down due to possible failure to thrive. Record review of the facility's policy on Assistance with Meals, dated March 2022, reflected, .facility staff will serve resident trays and will help residents who require assistance with eating . 676252 Page 4 of 10 676252 12/08/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 residents who need respiratory care were provided such care consistent with professional standards of practice for 1 of 1 (Resident #63) reviewed for tracheostomy care. Residents Affected - Some The facility failed to enter orders for Resident #63's oxygen therapy after she returned from the hospital on [DATE]. This failure could place residents at risk for respiratory compromise and associated complications such as respiratory distress and lung damage. Findings: Record review of Resident #63 face sheet revealed a [AGE] year-old female admitted [DATE] with a diagnosis of Sepsis, Unspecified Organism (Infection in the blood). Record review of Resident #63 MDS dated [DATE] revealed no BIMS (Brief Interview For Mental Status) summary score. Section C revealed cognitive skills for daily decision making was a 3. For severely impaired . Section GG revealed the resident was dependent for self-care abilities and mobility. Section I revealed active diagnoses Anemia (Low blood count), Hypertension (High blood pressure), Neurogenic Bladder (Lack of bladder control), Diabetes Mellitus (Body does not produce enough insulin), Cerebral Vascular Accident (Interruption of blood to the brain), Respiratory Failure (Difficulty breathing). Section O revealed Oxygen Therapy and Tracheostomy care (Breathing tube care ). Record review of Resident #63's orders revealed in part .O2 at 5L via trach conts to maintain O2 sats >92% .discontinue 9/29/2023. Record review of the nurse's notes dated 10/6/2023 at 6:11pm revealed resident returned from hospital transported by EMS with Oxygen at 5 liters, notes did not mention humidification. Record review of hospital discharge summary for Resident #63 dated 10/6/2023 revealed no orders or oxygen or humidification of oxygen. Observation of Resident #63 on 12/6/2023 at 10:00am revealed she had oxygen running at 5 liters with 40% humidification to the tracheostomy mask. Record review of Resident #63's physicians orders on 12/6/2023 at 10:00am revealed no active orders for oxygen. In an interview on 12/6/2023 at 10:00am RN A said the reason the order for the oxygen may have been missed was because the resident went to the hospital frequently. She said the admitting nurse was supposed to have put the order in when Resident #63 came back to the facility. She said the resident did not have orders for oxygen and said anything could have happened to Resident #63 and they should not have assumed anything. She said they needed physician's orders for oxygen because they were supposed to be following directions from doctors. In an interview on 12/6/2023 at 11:30am the DON said if they did not know how many liters of oxygen 676252 Page 5 of 10 676252 12/08/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a resident was supposed to be on and they did not have an order for it the process would have been to call the doctor and assess the resident. She said she did not know how the order for oxygen got missed. She said she did not know how much oxygen Resident #63 was supposed to be on because they did not have an order for it. In an interview on 12/7/2023 at 12:27pm the Respiratory Therapist said Resident #63's oxygen was set at 5L and 40% humidification. He said the last he had heard when Resident #63 got back from the hospital, those were the settings for her. He said he got his orders from the staff as he did not have access to the EHR. He said he was a contractor and when he came to the facility the nurses gave him the orders. He said he came once per week and performed trach care. He said he had assessed the stoma (Trach entry site) site. He said he had made notes for the physician and if they had wanted to make changes, he would make them. When asked what would happen to a resident if they did not have orders, he did not answer. In an interview on 12/8/2023 with LVN G she said she would look at the plan of care then look at the physician's order for a resident. She said she would not work without a physician's order as she would have been working out of her scope of practice. She said if the order for oxygen was not correct the resident's carbon dioxide levels could be off, and the resident could have lung damage. In an interview on 12/8/2023 at 9:44am with LVN H she said she had worked at the facility for four years. She said oxygen required a physician's order because it was a medication She said if a resident was given oxygen over a period of time without a physician's order the resident could have had respiratory distress because they could have gotten too much oxygen. She said getting the physician's order was important because when the resident was under their care it was not up to them to decide what care they got. In an interview on 12/8/2023 at 10:01am with MA A she said she had worked with a physician's order. She said she did not administer a medication just because she wanted to. She said she would have called the nurse practitioner for an order because she could not have made the decision for oxygen on her own. On 12/08/2023 at 3:09PM, a request for the policy on following physician's orders from the Administrator, but it was not provided prior to exit. 676252 Page 6 of 10 676252 12/08/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0880 Provide and implement an infection prevention and control program. 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 maintain an infection control program designed to ensure a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents reviewed for infection control (Resident #83) in that: Residents Affected - Few LVN E removed a packed dressing from Resident #83's left lower buttock and scratched and rubbed his back without changing her gloves. After cutting dirty dressing from Resident #83's foot LVN E placed small amount of hand sanitizer on a gauze and wiped the blades of her scissors and placed the scissors back on the clean field. These deficient practices placed resident at risk for infection and inadequate wound healing. Findings: Record review of Resident #83's face sheet no date revealed a [AGE] year-old male admitted on [DATE]. Resident #83's diagnoses were Anemia (Low blood supply), Acute and Chronic Respiratory Failure with Hypoxia (Not enough oxygen in your tissues for a long period of time), Non ST Elevation MI (Heart attack), Heart Failure (Heart not pumping enough blood), Pressure Ulcer of Other Site Stage 4 (Deep Wound), Pressure Ulcer of Left Buttock, Stage 4 (Deep wound), Non Pressure Ulcer of Skin of Other Sites with Fat Layer Exposed (Wounds form other causes), Non Pressure Chronic Ulcer of Right Calf With Fat Layer Exposed (Wound to right calf from other causes), Pressure Ulcer Sacral Region Stage 4 (Deep wound). Record review of Resident #83's Care Plan dated 6/22/23 reflected in part .[Resident #83] is at risk for impaired skin integrity due to impaired mobility, he is mostly bedbound .[Resident #83] will have no complications due to skin impairment through the review date Keep skin clean and dry .date initiated 8/25/2023 .[Resident #83] has stage 4 pressure ulcer to his left buttocks .date initiated 11/28/2023. Observation of Resident #83 for pressure ulcer treatment on 12/7/2023 at 9:49am performed by LVN E, revealed LVN E cleansed a bedside table with germicidal wipes and set up dressings and scissors on wax paper. When LVN E began wound care on Resident #83's left buttock, LVN E applied hand sanitizer, donned gloves and removed the top of the dressing from Resident #83's stage 4 wound from his left lower buttock. She then removed a packed dressing and Resident #83 asked LVN E if she would scratch his back and she said yes. LVN E scratched and rubbed Resident #83's back without changing her gloves. LVN E scratched Resident #83's whole back area. LVN E then removed her gloves, wiped her hands with hand sanitizer and donned new gloves. She cleansed the wound with wound cleanser and wiped, removed her gloves, used hand sanitizer, donned new gloves, and packed the resident's wound with ag silver rope (a dressing soaked with medication to stop the growth of bacteria) and covered with a bordered dressing. When LVN E began wound care to Resident #83's left foot she used hand sanitizer, donned new gloves, and used scissors to cut away the dressing covering Resident #83's left foot. The scissors underside touched skin, blades and top area of scissors touched dirty dressing. LVN E removed the dressing and placed the scissors on clean wound dressing area on the bedside table. LVN E removed her gloves, used hand sanitizer, and donned new gloves. LVN E put hand sanitizer on a gauze, wiped the bottom part of the blades and placed the scissors on the clean wound dressing area. LVN E did not sanitize the scissors. 676252 Page 7 of 10 676252 12/08/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0880 Level of Harm - Minimal harm or potential for actual harm In an interview on 12/7/2023 at 9:49am LVN E said she was not certified in wound care. She said she let her wound care certification expire but had been doing wound care for the past 10 years. In an interview on 12/7/2023 at 11:18am the DON said removing dirty dressings from a resident's wound and scratching and rubbing the resident's back with the same gloves on was not the standard of practice. Residents Affected - Few In an interview on 12/7/2023 at 11:40am LVN E said there could have been cross contamination when she scratched and rubbed Resident #83's back with her soiled gloves. She said when there was cross contamination, the resident could get an infection. She said she did not know she was not supposed to wipe her scissor blades with hand sanitizer because it was alcohol. She said she had antimicrobial cleanser in her cart but did not use it. When LVN E was informed other parts of her scissors touched the dressing and Resident #83's skin and she did not wipe all her scissors, she did not say anything . In an interview on 12/8/2023 at 9:44am with LVN F she said she had worked at the facility for four years. She said she would not have scratched a resident's back with the same gloves she removed a dirty dressing with because the gloves were already contaminated. She said this would have caused an infection. In an interview on 12/8/2023 at 11:50am the DON said she was continuously doing in-services on infection control on handwashing and use of gloves, recognizing signs and symptoms of an infection. She said the wound care nurse had training on infection control and wound care, she said the wound care nurse also rounded with the wound care physician. When asked where the recent trainings were prior to surveyor arrival, she did not provide them. Record review of facility policy titled, Infection Control, dated 2018, reflected in part . This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .the depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities . 676252 Page 8 of 10 676252 12/08/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to equip each room to assure full visual privacy for each resident for 3 of 10 dual rooms reviewed for privacy. Residents Affected - Some The facility failed to provide curtains that surround the bed to ensure residents' privacy in Rooms A, B, and C. The rooms did not have curtain tracks on the ceiling between resident beds for privacy curtains. No other means for visual privacy between beds was provided. This failure placed residents at risk of decreased self-worth and dignity by being exposed during resident care. Findings included: During an observation on 12/06/23 at 11:12 AM, Resident #76 was in room A, sleeping in bed. The resident had a roommate, Resident #90, but she was not present. Observed privacy curtain ceiling tracks between resident beds and privacy curtains were not there. During an observation on 12/6/23 at 1:15 PM of room B, privacy curtain ceiling tracks between resident beds and privacy curtains were not there. During an observation on 12/6/23 at 1:20 PM of room C, privacy curtain ceiling tracks between resident beds and privacy curtains were not there. Attempted interview on 12/07/23 at 11:00 AM with Resident #76 was unsuccessful. The resident was unable to respond appropriately to questions. Record review of face sheet for Resident #76 revealed admission to facility date of 7/7/23 to room A. Record review of face sheet for Resident #90 revealed admission to facility date of 4/28/23 to room A. Record review of face sheet for Resident #97 revealed admission to facility date of 9/7/23 to room B. Record review of face sheet for Resident #89 revealed admission to facility date of 2/21/23 to room B. Record review of face sheet for Resident #78 revealed admission to facility date of 3/10/23 to room C. Record review of face sheet for Resident #74 revealed admission to facility date of 3/1/23 to room C. Observation 12/08/23 09:05 AM revealed Resident#76 sleeping in their room. The roommate, Resident #90, was sleeping as well. Observed privacy curtain ceiling tracks between resident beds and privacy curtains not present. 676252 Page 9 of 10 676252 12/08/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0914 Level of Harm - Minimal harm or potential for actual harm In an interview on 12/8/23 at 10:35 AM, CNA 1 reported that when Resident #76 needed her briefs or clothes changed or other personal care in the room, she pulled the privacy curtain between beds. When it was pointed out to CAN 1 that the room does not have curtain tracks or curtains between the beds, she appeared surprised. CNA 1 reported that most of the time the roommate, Resident #90, is not usually present so privacy has not been an issue. Residents Affected - Some During an interview on 12/8/23 at 10:40 AM, CNA 2 reported that when Resident #76 needed personal care, she pulled the curtain between the beds. When it was pointed out to her that there were not any between bed curtains, she said that her roommate is not usually in the room. CNA 2 said she would contact maintenance to get the curtains replaced. Interview on 12/8/23 at 12:11 PM, the Maintenance Director reported that he does his daily environmental rounds every morning and evening to ensure there are no issues with the facility. When asked if he was aware of any missing privacy curtains, he stated that none were missing. When asked about the missing curtain tracks and privacy curtains for room A, B and C, he replied that he took the tracks and curtains down for cleaning on Monday, 12/4/23, but has not replaced them yet due to Surveyors being in the building and making him very busy. Interview on 12/8/23 at 1:55 PM, the Administrator reported that the Maintenance Director had just made her aware of the missing privacy curtains today. She reported that the Maintenance Director was replacing the curtain tracks and curtains today. He reported to her that the curtain rails had been ordered and had just arrived and he would be installing them today. Observation on 12/8/23 at 2:35 PM revealed curtain tracks being installed in room A. 676252 Page 10 of 10