Health inspection·September 20, 2023

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #102) reviewed for PASRR Level I screenings. Residents Affected - Few The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #102. The PASRR 1 Level screening did not indicate a diagnosis of mental illness, although the diagnosis was present upon admission. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #102's face sheet, dated 09/20/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included post-traumatic stress disorder (a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). The onset date was 08/18/23. Record review of Resident #102's admission MDS assessment, dated 09/21/23, indicated section A1500 was marked 0 or no. This indicated he was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section A1510 was not marked for level II PASRR conditions. The assessment indicated he had a BIMS score of 15, which indicated intact cognition. Record review of Resident #102's PASRR level 1 screening, dated 08/18/23, indicated section C0100 Mental illness was marked no, which indicated there was not evidence or an indicator that he had a mental illness. During an interview on 09/20/23 at 10:44 AM, the MDS Coordinator said she reviewed Resident #102's PASRR Level 1 assessment. She said she did not mark his PL1 as yes for mental illness. She said he had a diagnosis of PTSD and it should have been marked yes for mental illness. She said it was possible that the resident could have had PASRR services for his PTSD. She said she was going to resubmit a corrected PL1 to the local authority so that Resident #102 can be evaluated for PASRR services. During an interview on 09/20/23 at 02:01 PM, the ADON said she expected Resident #102's PASRR Level 1 to be marked yes for mental illness because of his diagnosis of PTSD. She said it was possible he could have qualified for services if it had been marked yes. Page 1 of 9 676262 676262 09/20/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 09/20/23 at 02:07 PM, the DON said she expected Resident #102 to have a positive PASRR level 1 for mental illness. She said it was possible if his PL1 was marked positive for mental illness he may have qualified for services. She said he had a diagnosis of PTSD. During an interview on 09/20/23 at 02:12 PM, the Administrator said Resident #102 was being seen by the VA for his PTSD. She said she expected his PASRR level 1 to be marked yes for mental illness. She said it was likely missed because they have not worked with the VA before. She said she was not sure if he would have qualified for PASRR services because he received services through the VA. Record review of the facility's policy, specialized rehabilitative services, dated February 2017, stated: .Specialized services for MI [mental illness] or MR [mental retardation] For a resident with MI or MR, the community will ensure that the individual receives the services necessary to assist him or her in maintaining or achieving as much independence and self-determination as possible. The preadmission screening and resident review (PASRR) indicates specialized services required by the resident. The state is required to list those services in the report, as well as to provide or arrange for the provision of the services. Even if the state determines that the resident does not require specialized services, the community is still responsible for providing all services necessary to meet the resident's mental health or mental retardation needs. The community provides interventions that complement, reinforce, and are consistent with any specialized services (as defined by the resident's PASRR) 676262 Page 2 of 9 676262 09/20/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #366) reviewed for respiratory care and services. Residents Affected - Few The facility failed to obtain a physician's order for oxygen administration for Resident #366. The facility failed to follow their oxygen administration policy This failure could place residents at risk for developing respiratory complications. Findings included: Record review of Resident #366's face sheet, dated 09/19/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area), and obstructive sleep apnea (a sleep disorder characterized by repeated obstruction to the airway during sleep). Record review of Resident #366's admission MDS assessment, dated 09/13/23, indicated she had a BIMS score of 06, which indicated she had severe cognitive impairment. She did not exhibit behaviors of rejection of care or wandering. She required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, toileting, and personal hygiene. The assessment indicated she did have oxygen therapy while not a resident. The assessment indicated she did not have oxygen therapy while a resident. Record review of Resident #366's physician's orders, dated 09/19/23, indicated she did not have an order for oxygen administration. Record review of Resident #366's care plan, created on 09/09/23, indicated a focus of I may be at risk for: self-care deficit, falls, skin concerns, pain, infection & nutritional/hydration concerns, and emotional distress. Interventions included: *Provide oxygen as ordered by physician. Follow community's protocols for changing tubing and filter cleaning as indicated. Further Record review of Resident #366's care plan, created on 09/09/23, indicated a focus of I am at risk for experiencing shortness of breath. Interventions included: *Alert my nurse for concentrator alarms and/or if my oxygen tank needs to be changed *Monitor for and report all abnormal and/or change in conditions to my doctor as indicated. *Monitor oxygen saturation as ordered by my doctor and as clinically indicated. *Provide oxygen as ordered/recommended by my physician. 676262 Page 3 of 9 676262 09/20/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0695 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #366's MAR for September 2023 indicated she did not have an order for oxygen administration. During an observation on 09/18/23 at 10:06 AM, Resident #366 was in her bed in her room. She had oxygen in place via a nasal cannula to her nose and the oxygen concentrator was set at 2 liters per minute. Residents Affected - Few During an observation on 09/18/23 at 12:25 PM, Resident #366 had oxygen in place via nasal cannula. The oxygen concentrator was set at 2 liters per minute. She was lying in bed underneath a blanket in her room. During an observation on 09/19/23 at 11:45 AM, Resident #366 was lying in bed underneath a sheet. She had oxygen in place via nasal cannula. The oxygen concentrator was set to 2 liters per minute. During an observation on 09/19/23 at 04:18 PM, Resident #366 had oxygen in place via nasal cannula. The oxygen concentrator was set to 2 liters per minute. She was lying in bed in her room. During an observation on 09/20/23 at 08:58 AM, Resident #366 had oxygen in place via nasal cannula. The oxygen concentrator was set to 2 liters per minute. She was lying in bed in her room underneath a blanket. During an interview on 09/20/23 at 10:40 AM, LVN D said she was taking care of Resident #366 on 09/20/23. She said Resident #366 did not have an order for oxygen. She said Resident #366 should have an order for the nurses to administer oxygen. She said that the risk to the resident was that the nurses may not know she had oxygen and may not know to monitor the oxygen. She said it was possible for Resident #366's oxygen to be set too high and it could lower her respiratory drive and possibly send her to the hospital. She said the nurses also would not know the flow rate to set the oxygen. During an interview on 09/20/23 at 02:01 PM, the ADON said she expected the nurse to have an order for oxygen administration for Resident #366. She said the risk to the resident was that it was possible that an agency nurse or someone that was not familiar with her care would not know to monitor her oxygen or know the correct flow rate. During an interview on 09/20/23 at 02:07 PM, the DON said she expected Resident #366 to have an order for oxygen administration. She said the normal process was that the nurse would get an order for oxygen on admission. She said the risk to the resident was that it was possible that not everyone would know to apply her oxygen without an order. She said if an agency nurse or someone that was not familiar with her care took care of her they could not know to monitor her oxygen. During an interview on 09/20/23 at 02:12 PM, the Administrator said she expected Resident #366 to have an order for oxygen. She said she was not clinical, so she was unable to guess what the risk was. She said the nurses should be checking vital signs to ensure her oxygen was set correctly. Record review of the facility's policy for oxygen administration, last revised January 2022, stated: .A resident receives oxygen therapy when there is an order by a physician. The resident's disease, physical condition, and age will help determine the most appropriate method of administration and should be reflected in the physician order. 676262 Page 4 of 9 676262 09/20/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0695 Procedure . Level of Harm - Minimal harm or potential for actual harm .3. Obtain physician orders for oxygen administration. Orders should include the following: a. oxygen source to be used (concentrator, tank, etc.) Residents Affected - Few b. method of delivery (cannula, mask, etc.) c. flow rate of delivery d. oxygen saturation monitoring parameters, if indicated 676262 Page 5 of 9 676262 09/20/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen and 4 of 4 satellite kitchens reviewed for food service. Residents Affected - Many Opened food packaging in the pantry and walk-in freezer were not closed after opening. Packages of food items were not labeled, dated, and re-sealed. A bulk container of popcorn had cups left inside the product. Food storage containers were not kept clean when stored. Satellite kitchens on the halls had soiled microwaves and dried coffee spills inside cabinet drawers. A carton of thickened liquid was not dated when opened. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations on 09/18/23, the following was noted in the kitchen: At 09:26 AM in the pantry a bulk plastic container of popcorn had a plastic cup and a Styrofoam cup stored inside the product. A plastic bag of raisin bran placed inside a zippered bag was not closed or dated and labeled. A 35 oz. bag of corn flakes was placed inside a zippered bag was not closed or labeled and dated. At 09:28 AM in the pantry an opened 16 oz. box of powdered sugar was not re-sealed or placed in a zippered bag. At 09:35 AM in the walk in freezer a case of beef patties was opened and the inner liner bag was left open and not re-closed. At 09:38 AM 2 plastic containers below the soup prep table had food debris present in the bottom of the containers and dried drips of a light brown unknown liquid. The containers were greasy to touch. During observations on 09/20/23, the following was noted in the satellite kitchens: At 1:50 PM in the hall 100 dining area: the microwave had splatters over all sides, was heavily stained and had a basket of French fries inside. The drawer under the coffee machine had dried drips of coffee in the bottom and on the top edges of the drawer. At 1:58 PM in the hall 200 dining area: the microwave had splatters over all sides and was heavily stained. The drawer under the coffee machine had a large pool of dried coffee in the bottom and 676262 Page 6 of 9 676262 09/20/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dried drips on the top edges of the drawer. In the refrigerator there was one 46 oz. container of nectar thick orange juice that was not dated when it was opened. The packaging indicated After opening may be kept up to 7 days under refrigeration. At 2:07 PM in the hall 300 dining area: the microwave had splatters over all sides and was heavily stained. In the freezer there was a frozen gel pack that had a vanilla ice cream like substance frozen to the outside. At 2:17 PM in the hall 400 dining area: the microwave had splatters over all sides and was heavily stained. The drawer under the coffee machine had drips of dried coffee in the bottom and dried drips on the top edges of the drawer. During an interview on 09/19/23 at 5:00 PM, the DM said she had gone behind the surveyor and noticed the cups in the bulk bin of popcorn. She said weekend staff sometimes do not always keep things the way they have been taught to keep them. She said all dietary workers were trained to date, label, and re-seal opened items She said they had been taught to not store cups or scoops in the bulk storage bins. She said she removed the soiled containers from under the soup prep table. She said they were odd containers and lids. She said the containers did not have lids that fit and the lids did not have containers that fit so she threw them all away. She said they should have been thrown away a long time ago. She said the dietary staff were responsible for the satellite kitchens and they were to wipe down everything after each meal service. She said she made sure the refrigerators were clean and wiped down but did not indicate a schedule of doing so. Review of a Preventing Foodborne Illness-Food Handling Policy revised July 2014 indicated Policy Statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Review of The Texas Administrative Code (TAC) indicated the following: Preventing Contamination From Equipment, Utensils, and Linens. (a) Food shall only contact surfaces of: (1) equipment and utensils that are cleaned . and sanitized . Frequency of Cleaning. .(c) Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues The Food and Drug Administration Code at http://www.fda.gov/food/guidanceregulation current as of 02/03/2021 indicated the following: .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. 676262 Page 7 of 9 676262 09/20/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0812 . Food Storage Level of Harm - Minimal harm or potential for actual harm Food shall be protected from contamination by storing the food: (1) In a clean, dry location; Residents Affected - Many (2) Where it is not exposed to dust or other contamination . . Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils . .(A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . 676262 Page 8 of 9 676262 09/20/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on an interview and record review, the facility failed to ensure that the facility's medical director or his/her designee attended the Quality Assessment and Assurance/Quality Assurance and Performance Improvement Committee meetings, for 1 of 1 facility, reviewed for QAA/QAPI. Residents Affected - Many The facility failed to ensure the medical director attended their QAA and QAPI meetings for the months of January 2023, February 2023 and March 2023. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: Review of the facility's QAA/QAPI meeting signature logs for the months of January through March 2023, revealed, meetings were conducted each month during that period. Neither the Medical Director nor his/her designee signed the sign-in sheets, nor was it indicated on the sign-in sheet that the Medical Director or his designee attended the QAA/QAPI meetings from January 2023 to March 2023, via zoom or by phone. The signature sign-in log also indicated, the Medical Director only attended 5 of 13 monthly QAA/QAPI meetings. During an interview on 09/20/2023 at 3:07 PM, the Administrator said the Medical Director receives a reminder letter of the QAA/QAPI meeting and sometimes they try to engage him by phone. She said she does not know why he did not attend the meetings, but they have a new Medical Director now. Review of the facility's policy Quality Assurance and Performance Improvement, dated February 2017, revealed, Compliance Guideline: The committee meets at least quarterly, and consist of the Director of Nursing, a physician designated by the community and at least 3 other community team members. 676262 Page 9 of 9