Health inspection·April 15, 2025

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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 9 residents (Resident #1) reviewed for care plans. The facility failed to develop a comprehensive care plan which addressed and included measurable objectives and timeframes related to Resident #1's indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to drain urine), which he had from approximately 01/29/2025 until 04/09/2025. This failure placed residents with indwelling urinary catheters at risk of experiencing urethral/bladder/kidney injury, pain, and possible infection. Findings include: Record review of Resident #1's face sheet dated 04/11/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE] and most recently re-admitted on [DATE]. He was diagnosed with infection and inflammatory reaction due to indwelling urethral catheter, type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), chronic kidney disease, stage 4 (significant decline in kidney function, nearing kidney failure), hypertensive heart disease with heart failure (when prolonged high blood pressure weakens the heart muscle, eventually leading to the heart's inability to pump blood effectively), and cognitive communication deficit (difficulties with communication caused by problems with underlying cognitive processes). Record review of Resident #1's significant change MDS dated [DATE] revealed he had a BIMS score of 4 (severe cognitive impairment); Resident #1 used a walker and manual wheelchair for ambulation; Resident #1 was dependent on staff for toileting; Resident #1 had an indwelling catheter; Resident #1 was frequently incontinent of bowel; Resident #1 was diagnosed with renal insufficiency (also called renal failure - when the kidneys lose the ability to remove waste and balance fluids)/renal failure/ or end-stage renal disease (see renal failure); and Resident #1 had been diagnosed with a UTI (an infection that can affect any part of the urinary system) within the previous 30 days. Record review of Resident #1's baseline care plan dated 03/17/2025 revealed, . 3. Health Conditions Page 1 of 5 676252 676252 04/15/2025 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0656 . C. Bowel and Bladder. 1. Urinary continence - Always continent . 4. Bowel and bladder appliances Indwelling catheter . Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's physician's orders for February 2025 - April 2025 revealed the following: Residents Affected - Few * Flush [catheter] with 60cc's NS every day, PRN, every shift. Start date: 02/01/2025. End date: 02/11/2025. * [Catheter] care: Output Q shift every day and night shift. Start date: 02/01/2025. End date 02/11/2025. * Change [Catheter] and drainage bag PRN for obstruction or when closed system is compromised as needed. Start date: 02/25/2025. End date: 03/07/2025. * Flush [catheter] with 60cc's NS every day, PRN, as needed. Start date: 02/26/2025. End date: 03/07/2025. * Flush [catheter] with 60cc's NS every day, PRN, every shift. Start date: 03/18/2025. End date: 04/11/2025. * [Catheter] care: Output Q shift every day and night shift. Start date: 03/17/2025. End date 04/09/2025. Reason: [Catheter] discontinued. * Remove [catheter], if not voided in 8 hours, replace [catheter] one time only for 1 day, remove at 3:00 p.m. Order date 04/09/2025. End date: 04/10/2025. Record review of Resident #1's comprehensive care plan, revised 04/09/2025 revealed the following care areas: * [Resident #1] has acute renal failure. Goal included: [Resident #1] will have no s/sx of complications related to fluid deficit (dehydration - when the body loses more fluid than it takes in). Interventions included: Give medications as ordered by physician. Monitor changes in mental status. 676252 Page 2 of 5 676252 04/15/2025 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0656 Monitor for s/sx of infection, UTI. Monitor lab reports of electrolytes and report to physician. Level of Harm - Minimal harm or potential for actual harm * Residents Affected - Few [Resident #1] has incontinence and limited mobility due to his multiple comorbidities putting him at risk for skin breakdown. Goal included: The resident will maintain or develop clean and intact skin. Interventions included: Encourage good nutrition and hydration. Keep skin clean and dry. * [Resident #1] has urinary incontinence putting him at risk for having a UTI. Goal included: Resident #1's risk for septicemia (blood poisoning - a bloodstream infection where bacteria and their toxins are carried throughout the body) will be minimized/prevented via prompt recognition and treatment of symptoms of UTI. Interventions included: Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Ensure the resident has an unobstructed path to the bathroom. Incontinent: Check every 2 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. * [Resident #1] is at risk for renal insufficiency due to him having chronic kidney disease stage 4. Goal included: Resident #1 will have no s/sx of complications related to fluid deficit. Interventions included: Monitor/document/report PRN any s/sx of acute renal failure. Further review of Resident #1's comprehensive care plan revealed no care area to address his indwelling urinary catheter. Record review of Resident #1's nursing progress notes for January 2025 - April 2025 revealed the following: * On 01/29/2025 at 6:00 a.m., an unidentified staff member wrote, admission details: Arrived by: ambulance. admission mode: stretcher . * On 01/30/2025 at 4:14 p.m., RN C wrote, Re-admit day 2/3 (Resident #1 was readmitted to the facility on [DATE]. There was no documentation about a catheter before this date). Resident is alert and oriented to self and situation . Resident's [catheter] is patent and draining clear, yellow urine. No color noted . * On 02/09/2025 at 1:01 a.m., LVN B wrote, . Genitourinary (urinary and genital organs): Catheter character: Patent (open or unobstructed). Catheter in place due to urinary retention (the inability to completely empty the bladder when urinating). Catheter size: 16 . * 676252 Page 3 of 5 676252 04/15/2025 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/09/2025 at 4:55 a.m., LVN A wrote, Late Entry. Resident [catheter] discontinued per RP request and NP orders and tolerated well. Will monitor urine output through night per orders to reinsert if output not sufficient. Observation and interview with Resident #1 on 04/11/2025 at 1:05 p.m. revealed he was alert and spoke Spanish. Through an interpreter with the HHSC approved language line, Resident #1 provided his name and birthdate. He did not have a catheter at that time. In an interview with the DON on 04/15/2025 at 10:45 a.m., she stated Resident #1 had a catheter at one time, but it was removed last week. She said she could not recall why Resident #1's catheter was removed, but she did not think he had it for a long time. In a follow-up interview with the DON on 04/15/2025 at 12:58 p.m., she stated Resident #1 may have returned from the hospital with the catheter on 3/17/2025. She said Resident #1's catheter should have been listed as a care area on his care plan to inform staff how to care for it and to communicate what was going on with him. She said she was surprised to hear that Resident #1's catheter was not mentioned on his care plan. She stated the MDS Nurse was responsible for updating care plans and she was going to ask the MDS Nurse why there was no care area related to Resident #1's catheter. In an interview with Resident #1's Physician on 4/15/2025 at 1:28 p.m., she stated her records indicated Resident #1 first had the catheter around 02/08/2025 due to urinary retention. She said the purpose of a care plan was to ensure staff knew what to do regarding the care areas, like Resident #1's catheter. She said staff never contacted her about any issues with Resident #1's catheter. She said as far as she knew, Resident #1's family requested to remove the catheter because they were taking him home. In an interview with the MDS Nurse on 04/15/2025 at 2:30 p.m., she stated she was responsible for updating residents' care plans. She said she and her assistant received information from morning staff meetings and the DON gave them lists of residents with feeding tubes, catheters, and tracheostomy tubes (a surgical procedure that creates an opening in the neck to insert a tube directly into the trachea). She said if any resident had a change in condition, she or her assistant would update their care plan. The MDS Nurse initially stated her assistant resolved (removed from the care plan) Resident #1's catheter information on 04/11/2025. She said Resident #1 was readmitted on dialysis on 03/17/2025, so she and her assistant completed a significant change assessment (completed a significant change MDS). She stated any resolved care area on a care plan would still be visible in their computer system. After reviewing Resident #1's comprehensive care plan on her computer, the MDS Nurse stated she did not see any care area related to Resident #1's catheter. She stated she was on leave when Resident #1 readmitted , but she heard the team (the nursing staff) talk about Resident #1 when she returned to work. The MDS Nurse stated she did not see any care area related to Resident #1's catheter which would have resolved from the care plan. She said Resident #1's catheter was addressed on his MDS and baseline care plan, but it did not carry over to his comprehensive care plan. She said the purpose of the care plan was to ensure all the staff knew each residents' plan of care and what interventions were in place. She said the care plan was also for new staff who were not familiar with the residents. She stated there were no negative effects related to Resident #1's catheter not being addressed on his care plan, but a negative effect would be that staff would not know information, like when to change him or how to care for him, and that could lead to infection. In an interview with the DON on 04/15/2025 at 3:00 p.m., she said Resident #1 had the catheter in February 2025. She said Resident #1 was discharged to the hospital and returned with the catheter. 676252 Page 4 of 5 676252 04/15/2025 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She stated Resident #1 did not experience any negative effects from not having the catheter addressed on his care plan because the staff followed orders from his physician. She said a negative effect would be infection. Record review of the facility's policy, titled, Care Plans, Comprehensive Person-Centered revised March 2022 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . c. includes the resident's stated goals upon admission and desired outcomes; . e. Reflects currently recognized standards of practice for problem areas and conditions . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; . c. when the resident has been readmitted to the facility from a hospital stay . 676252 Page 5 of 5