Health inspection·October 30, 2024

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. 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 residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls could be made without being overheard for 3 of 7 residents (Residents #4, #27, #33, #36, #53, #58 and #85) reviewed for telephone use. Residents Affected - Few The facility failed to provide a phone that could be used in an area, which would prevent resident conversations from being overhead. This failure could place residents at risk of having conversations being overheard and privacy rights not being respected. The findings included: During a group interview on 10/29/24 at 9:30 AM, Residents #4, #31 and #36 said the facility did not provide a phone for them to use, that would allow them to have a private conversation. They said the facility did not have a cordless phone for them to use and they had to use the phone at the nurse's station or the phone at the reception's desk. During an interview on 10/29/24 at 10:43 AM, LVN-A said the facility used to have a cordless phone, but they didn't anymore. She said she was not sure what happened to the cordless phone. During an interview on 10/29/24 at 10:43 AM, the Workforce Manager said the facility did not have a cordless phone; they used too but they don't have one now. During an interview on 10/29/24 at 10:48 AM, LVN-C said they did not have a cordless phone. She said she believed it stopped working when the facility was having a new system installed. During an interview on 10/29/24 at 10:54 AM, the ADM said the facility did not have a cordless phone. She said they used to have one, but not at this time. She said the residents could use an office. She said she could get a new cordless phone today. During an interview with Resident #4 on 10/29/24 at 11:47 AM, she said she didn't know where she could go for a private conversation. She said she had just used the phone at the nurse station, and everyone could hear her conversation. During an interview with Resident #31on 10/29/24 at 11:51 AM, she said she would not know where to go for a private phone conversation. She said she could not go anywhere but the nurse's station. Page 1 of 6 676262 676262 10/30/2024 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0576 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Resident #36 on 10/29/24 at 12:53 PM, he said he did not have a cell phone, he had to use his [NAME] device. He said when he received a phone call, there was no private place for him to take the phone call. He said he would have to take it at the nurse's station or the reception's desk, and that's not private. During an interview with the Activity Director on 10/29/24 at 2:16 PM, she said the residents could go to the nurse station, the front desk or they could go to an office, to use the phone. She said that issue had never come up in a Resident Council meeting and she had never discussed where residents could go for private phone conversations. During an interview with the ADM on 10/29/24 at 2:26 PM, she said the facility did not have a policy on resident phone use. 676262 Page 2 of 6 676262 10/30/2024 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Residents #6) reviewed for pharmacy services. The facility failed to ensure a physician's order provided clearly written instructions for the dose of cholecalciferol (Vitamin D3) Resident #6 was to be given. This failure could place residents at risk for not receiving accurate doses of medications and the intended therapeutic response of prescribed medications. Findings included: A record review of Resident #6's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Dementia (a group of thinking and social symptoms that may interfere with daily functioning) and Vitamin D (cholecalciferol) Deficiency. A record review of Resident #6's MDS dated [DATE] noted Resident #6 had a BIMS score of 15 which indicated her cognition was intact. A record review of Resident #6's October 2024 physician orders and MAR reflected an order dated 06/06/2022 for Resident #6 to be given Cholecalciferol capsule give 50,000 unit by mouth every Thursday. The order did not specify the strength of the cholecalciferol capsules being supplied nor the number of capsules to be given to equal the ordered dose of 50,000 unit. During an observation and interview on 10/30/2024 at 11:45 AM, MA A withdrew a bottle labeled Vitamin D3 5000 IU from the medication cart and said she gave 1 (one) capsule from the bottle to Resident #6 every Thursday. She said she did not know if Vitamin D3 and cholecalciferol were the same thing. She said she did not know if unit and IU were the same thing. She said the name of the medication on the physician's order should match the name of the medication on the bottle. She also said the order should say what strength the capsules in the bottle were and how many of those capsules to give to meet the ordered dose. MA A said medication aides were not allowed to calculate how many capsules were to be given. MA A said the order was not clear and could result in Resident #6 getting an inaccurate dose. MA A said she should tell the nurse if a physician's order did not match the label on the medication container or if an order was unclear. She said she had not told the nurse. During an interview with LVN B on 10/30/2024 at 10:40 AM, she said cholecalciferol 50,000 IU was not available as a stock medication. She said it would come from the pharmacy on a card with a label which contained instructions for administration. During an interview with the DCO on 10/30/2024 at 11:55 AM, she said she would clarify Resident #6's physician order for cholecalciferol and let the pharmacy know. A record review of the facility's policy Medication Administration reflected the following: 676262 Page 3 of 6 676262 10/30/2024 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2.b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any reason to question the dosage or directions, the physician's orders shall be checked for the correct dosage schedule. c. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved. A record review of the Texas Administrative Code: Title 26: Part 1: Chapter 557: Rule 557.105 indicated the following: A medication aide permitted under this chapter may not: (5) calculate resident's or client's medication dosages for administration . 676262 Page 4 of 6 676262 10/30/2024 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

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 observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #304) reviewed for infection control practices. Residents Affected - Few 1.RN A failed to don appropriate PPE prior to providing wound care to Resident #304. 2.CNA B failed to don appropriate PPE prior to providing incontinent care to Resident #304. These failures could place the residents under their care at risk for exposure to possible transmission of communicable diseases and infections. Findings included: A record review of Resident #304's face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #304 had diagnoses which included cerebral infarction (stroke), heart failure, chronic kidney disease, and indwelling urethral catheter (a thin tube that is inserted into the bladder through the urethra to drain urine). A review of Resident #304's admission assessment dated [DATE] reflected she had a foley catheter (a flexible tube that is left in place and drains urine from the bladder into a collection bag) and open wounds to her coccyx, sacrum, and buttocks. A record review of Resident #304's physician orders reflected an order dated 10/29/2024 for EBP. An observation during the initial tour of the facility on 10/28/2024 at 11:02 AM, revealed RN A, RN B, and RN C to be at the bedside of Resident #304. RN A was noted to be wearing disposable gloves while providing wound care to Resident #304's upper buttocks. She applied small squares of collagen (a type of dressing used to promote healing) to several open wounds on the Resident's upper buttocks area and covered them with a clean, dry dressing. RN A did not have a disposable gown on over her clothing. RN B was assisting RN A and RN C was observing the care from the foot of the bed. RN B and RN C did not make any comments regarding the absence of or need for a disposable gown during the provision of wound care. After completion of the wound care, RN A, RN B, and RN C left the room. As they left the room, CNA B entered the room carrying a bag with incontinent care items which included a disposable brief. CNA B donned a pair of disposable gloves and proceeded to complete the incontinent care. CNA B did not put a gown on to cover her clothing. There was no signage on the door nor on the wall outside the door to communicate the need for EBP. An observation on 10/28/2024 at 04:41 PM revealed there was no signage on the door of Resident #304's room to indicate the need for EBP. An observation on 10/29/2024 at 08:12 AM revealed Resident #304 had sign on her door which indicated EBP was to be used when providing direct care activities. During an interview with RN A on 10/30/2024 at 11:30 AM, she said she was the Infection Preventionist. She said EBP signs were to be placed on the doors upon residents' admission to the facility if 676262 Page 5 of 6 676262 10/30/2024 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0880 Level of Harm - Minimal harm or potential for actual harm indicated. She said residents with indwelling devices and wounds required EBP. She said Resident #304 required EBP because she had open wounds and a foley catheter. She said she did not put a disposable gown over her clothes when she provided Resident #304 wound care. RN A said she should have put a gown on prior to initiating wound care. She said the purpose of EBP was to reduce the risk for the spread of infection. Residents Affected - Few During an interview on 10/30/2024 at 12:05 PM, the staffing coordinator said CNA B was an agency aide and was not available for interview. During an interview on 10/30/2024 at 04:12 PM, RN D said an EBP sign on a resident's door meant gloves and gowns were to be worn when providing direct care to the resident. During an interview with CNA C on 10/30/2024 at 4:15 PM she said she was supposed to wear gloves and a gown when caring for a resident with an EBP sign on the door of their room. A record review of the facility's policy titled Infection Prevention and Control dated 03/13/20219 reflected the following: EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing Residents/Patients with the following clinical indication should be under EBP: Significant Wounds such as chronic wounds, ulcers, open PUI, or complicated/non-healing incisions or wounds and/or wounds requiring a dressing Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. EBP should be utilized during high-contact care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use ., wound care. 12. Implementation of Isolation and/or Precautions: Post clear signage .on the door or wall outside of the resident room indicating the type of Precautions and required PPE For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves . A record review of the facility's policy titled Professional Standard of Care reflected the following: Practices a)Licensed nurses should practice within the constraints of applicable state laws and regulations governing their practice and should follow the guidelines contained in the communities' written policies and procedures 676262 Page 6 of 6