Health inspection·February 21, 2025

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 observations, interviews, and record review the facility failed to provide the necessary care and services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 resident (Resident #1) of 11 residents reviewed for ADLs. Residents Affected - Few The facility failed to ensure Resident #1's fingernails were cleaned and trimmed on 2/21/2025. These failures could place residents at risk for loss of dignity due to not receiving care and assistance with daily living activities. Findings included: Record review of the undated face sheet for Resident #1 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), muscle weakness (decreased strength in the muscles), renal insufficiency (inability for the kidney to remove waste), dementia (memory loss), anxiety (worry or fear about everyday situation). Record review of Resident #1's Quarterly MDS dated [DATE] revealed her BIMS was code at 13 indicating she was cognitively aware for decision making. She had no behavior issues. For functional abilities she needs supervision for eating and hygiene, for toileting and lower dressing she was substantial/maximal assist, and for shower/bath, upper body dressing, personal hygiene and taking off and putting on footwear she was partial or moderately assisted. For bowel and bladder, she was frequently incontinent. Record review of Resident #1's care plan effective date 02/21/2025 revealed: Problem: Rejection of care: Resident #1 rejects or resists care ADL assistance, showers, nails, getting out of bed. Goals: Negative outcomes related to resistance to care will be minimized over the next 90 days. Intervention: Identify times/approaches, approaches/staff that result in least resistance. Communicate to all caregivers. Notify physician. Seek different forms of the drug. Talk to Resident #1 and family about reasons for refusal of care and potential risks. When care is refused, remind resident of potential risk. Coax but do not force compliance. Page 1 of 7 676323 676323 02/21/2025 The Crescent 11353 Sugar Park Lane Sugar Land, TX 77478

F 0677 Level of Harm - Minimal harm or potential for actual harm Observation on 2/21/2025 at 2:25pm revealed Resident#1 was in bed. She was alert and oriented with some confusion. She was dry with no offensive odor. Resident was observed with long nails to right hand and long dirty nails to the left hand. An interview was attempted with Resident #1 regarding her finger nails, but the resident did not respond. Residents Affected - Few In an interview on 02/21/2025 at 2:25pm with Staffing Coordinator CNA A she said she was going to ensure that Resident #1's nails were cleaned. She said the resident was not diabetic and she was going to ask the nurse if she could trim the resident's nails. Record review of Resident #1's the shower sheet revealed her shower days were Monday, Wednesday and Friday. Record review of the ADL shower sheet dated 02/21/2025 revealed she had a bed bath on 02/21/2025 in the morning and refused nail care. Further record review of the shower sheet revealed the section for Charge Nurse's assessment and intervention were blank. In an interview on 02/21/2025 at 2:30pm with CNA B she said she provided care for Resident #1 that morning. She said she cleaned her down, but she did not clean the resident's nail because the resident would not allow her to clean her nails. She said she did not report to the nurse that the resident had refused nail care. Further interview with CNA B revealed that if a resident refused care, she should report it to the nurse. No reasons were given by the CNA why she did not report the resident refusing nail care to the nurse. In an interview with the DON on 2/21/2025 at 2:55pm she said nail care was the responsibility of all CNAs and Nurses. She said staff were in-service recently on showers, incontinent care, and ADL care. She said when ADL care was done and there are any changes in a resident condition, or the resident refuse care the nurse should be notified. She said her expectation of the CNA was to report residents refusal of shower or nail care to the nurse and the nurse should try to clean and trim the nails. She said Resident #1 was not diabetic so the nurse could trim her nails. She said the last time the Podiatrist was in the building was in November 2024. Record review of the facility policy and procedures dated March 3/2018 on Activities of Daily Living (ADL's) read in part . Policy Statement: Resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Resident who are unable to carry out ADL independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Policy interpretation 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident/family in accordance with the plan of care including appropriate support and assistance with: Hygiene (bathing, dressing, grooming and oral care). 676323 Page 2 of 7 676323 02/21/2025 The Crescent 11353 Sugar Park Lane Sugar Land, TX 77478

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 2 of 11 residents (CR#3, Resident #4) reviewed for pharmacy services. The facility failed to ensure that CR#3 and Resident #4 received their prescribed medications, as ordered by their physician. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes by not documenting when medications were given or not given. Findings included: Record review of CR #3's face sheet dated 02/04/2025 revealed CR#3 was a 67 year olf female who was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. CR # 3's diagnoses included hyperthyroidism(overproduction of thyroid hormone), dementia (condition characterized by progressive or persistent loss of intellectual functioning), depression (a mental health condition with low mood and loss of interest in pleasurable activities), pain, insomnia ( difficulty falling asleep), hypotension ( a condition where the blood pressure was lower than normal), lack of coordination (a condition that affects the ability to control and execute movements), vitamin deficiency (deficiency of essential vitamins), protein calorie malnutrition(lack of sufficient energy and protein in the body), neurogenic bowel(loss of bowel function caused by nerve problem) osteomyelitis (inflammation of the bone), injury of C5level of cervical spinal cord (damage to the 5th cervical vertebra in the neck resulting in paralysis), quadriplegia (loss of motor and sensory function in all four limbs), muscle weakness (decreased strength in the muscles), dysphagia (difficulty swallowing) and neuromuscular dysfunction of bladder (bladder impaired due to damage nerve or muscles). Record review of CR# 3's Quarterly MDS dated [DATE] revealed she had a BIMS score of 14 indicating she was cognitively aware; she was coded as not exhibiting any behaviors. She was dependent on staff for ADL care which included eating, and toilet use, shower, dressing upper and lower body, putting on and taking off footwear, and personal hygiene. For bowel and bladder, she was coded as having a foley catheter and was always incontinent of bowel. In a confidential interview on 02/04/2025 at 11:00am it was revealed that CR#3 did not get her thyroid medications. The complaintant also stated that on the weekend of 01/25/2025 CR#3 had to beg for her thyroid medications. Record review of CR#3's physician's orders for January 2025 revealed the following active medication orders: Levothyroxine tablet 75mcg, give 1 tablet by orally one time a day related to hypothyroidism. Active 1/19/2025 Midodrine tablet 10mg, give 1 tablet orally three times a day related hypotension. Active 01/18/2025 676323 Page 3 of 7 676323 02/21/2025 The Crescent 11353 Sugar Park Lane Sugar Land, TX 77478

F 0755 Melatonin tablet 3 MG, give 1 tablet orally one time a day related to Insomnia. Active 10/1/2024 Level of Harm - Minimal harm or potential for actual harm Sertraline 50mg, give 1 tablet orally one time a day related to depression. Active 01/18/2025 Ascorbic Acid 500mg, give one tablet by mouth one time a day for vitamins. Active 1/18/2025. Residents Affected - Some Cipro oral tablet 500mg, give 1 tablet by mouth one time a day related to infection. Active 1/18/2025. Gabapentin 300mg, give 3 capsule orally every 8 hours for pain. Active 01/18/2025 Doxycycline 100mg, give 1 tablet by mouth one time a day for wound infection. Active 01/18/2025 Record review of CR#3's medication administration record for January 2025 revealed the following medications were not documented as given on the following days: Levothyroxine tablet 75mcg was not documented as given on 01/22/2025, 01/23/2025, 01/25/2025 and 01/27/2025 at 5:00am. Midodrine tablet 10mg was not documented as given at 8:00am and 12:00 noon on 1/20/25, 1/22/25-1/24/25 and 1/29/20275. Melatonin tablet 3 mg for insomnia was not documented as given on 1/25/2025 at 8:00pm. Sertraline 50mg, for depression was not documented as given from 1/20/25-1/24/25 and 1/29/2025 at bedtime. Ascorbic Acid 500mg for wound healing was not documented as given on 1/20/25, 1/21/25-1/24/2025 and 1/29/25 at 8:00am. Cipro oral tablet 500mg for infection was not documented as given on 1/20/25, 1/22/25-1/24/25 and 1/28/25 at 8:00am. Gabapentin 300mg for pain was not documented as given at 1:00am on 1/22/2025, 1/23/2025 and 1/25/2025 at 9:00am on 1/20/25, 1/22/2025-1/24/2025 and 1/29/2025 and at on 1/25/2025 at 5:00pm. Doxycycline 100mg, for wound infection was not documented as given at 9:00am on 1/20/2025, 1/22/25-1/24/2025 and 01/29/2025. Record review of CR#3's nurse's progress notes dated January 18 to January 30th, 2025 revealed no documentation as to why the medications were given or not given. Further record review revealed no documentation that CR#3 refused her medications. Resident #4 Record review of Resident #4's face sheet dated 02/04/2025 revealed Resident #4 was a [AGE] year old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included essential hypertension (high blood pressure), diabetes (high blood sugar), depression (a mental health condition with low mood and loss of interest in pleasurable activities), hyperlipidemia(high level of fat in 676323 Page 4 of 7 676323 02/21/2025 The Crescent 11353 Sugar Park Lane Sugar Land, TX 77478

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the blood),peripheral vascular disease (narrowing blood vessel that reduce blood flow to the limbs), GERD (acid reflux) Insomnia (difficulty sleeping), and Alzheimer disease (a progressive disease that affects memory and other mental functions). Record review of Resident #4's Annual MDS dated [DATE] revealed she was moderately impaired for cognitive skills for decision making. She was coded as not exhibiting any behaviors. She need supervision for eating and oral hygiene. She was dependent on staff for toileting and lower body dressing and needed substantial/maximal assistance for ADL care which included shower, upper body dressing, putting on and taking off footwear, and personal hygiene. For bowel and bladder, she was coded as frequently incontinent. Observation of Resident #4 on 2/19/2025 at 10:30am revealed the resident was up in her wheelchair, she was alert and speak mostly Spanish, she was clean and groomed with no offensive odor. No visible marks or bruises observed. Record review of Resident #4's physician's orders for January 2025 revealed the following active medication orders: Furosemide tab 20mg, give 1 tablet by mouth two times a day related to edema. Active 12/01/2024. Atorvastatin tab 10mg, give 1 tablet orally at bedtime related to hyperlipidemia. Active 12/28/2024. Melatonin tablet 5 MG, give 1 tablet orally by mouth at bedtime related to Insomnia. Active 12/12/2024. Omeprazole cap 40mg, give 1 tablet by mouth at morning related to GERD. Active 12/29/2024. Ascorbic Acid 500mg, give one tablet by mouth two times a day for vitamins. Active 12/01/2024. Gabapentin 300mg, give 1 capsule orally three times a day for neuropathy. Active 12/01/2024 Record review of Resident #4's medication administration record for January 2025 revealed the following medications were not documented as given on the following days: Furosemide tab 20mg, give 1 tablet by mouth two times a day for edema were not documented as given on 1/20/2025-1/24/2025 and 1/28/2025 at 9:00pm. and was not documented as given between 1/20/2025 and 1/23/2025 at 3:00pm and 9:00pm. Atorvastatin tab 10mg, give 1 tablet orally at bedtime for hyperlipidemia was as given between 1/20/2025 and 1/24/2025 and 1/28/25 at 8:00pm. Melatonin tablet 5 MG, give 1 tablet orally by mouth at bedtime for insomnia was not documented as given between 1/20/2025 and 1/24/2025 at 9:00pm. Omeprazole cap 40mg, give 1 tablet by mouth at morning GERD was not documented as given on 1/3/2025, 1/5/2025, 1/8/2025, 1/12/2025, 1/14/2025, 1/20/2025, 1/21/2025, 1/23/2025, 1/26/2025, 1/28/2025-1/31/2025 at 5:00am. 676323 Page 5 of 7 676323 02/21/2025 The Crescent 11353 Sugar Park Lane Sugar Land, TX 77478

F 0755 Level of Harm - Minimal harm or potential for actual harm Ascorbic Acid 500mg, give one tablet by mouth two times a day for vitamins was not documented as given between 1/20/2025 and 1/23/2025 and on 1/28/2025 at 9:00pm Gabapentin 300mg, give 1 capsule orally three times a day for neuropathy was not documented as given between 1/20/2025 and 1/23/2025 at 3:00pm and 9:00pm and on 1/28/2025 at 9:00pm. Residents Affected - Some Record review of Resident #4's nurse's progress notes dated January 2025 revealed no documentation as to why the medications were not given or if the resident had refused the medication. In an interview on 2/19/2025 at 12:55pm with Unit Manager C she said if medications were administered, or the resident refused it should be documented. She said there should be no holes on the MARS. She said medications given should be documented and if it was not given it should be documented and the reason why it was not given. In an interview on 2/19/2025 at 1:10 pm with RN A she said if medications were given it should be documented and if it was not given it should also be documented and the reason why it was not given. She said if there were no documentation on the MARs it would be difficult to determine if the was given or not given. She said there should be no blanks on the MARS. In an interview on 2/19/2025 at 1:15pm with the DON she said there should be no blanks on MARs. She said the expectation of the nurses were to sign the MARs whether the medications were given or not given. She said if there were blanks on the MARs it would be difficult to determine if the meds were given or not given and would result in the resident been overmedicated or not getting their medication. She said she was going to in-service the nurses. In an interview on 2/19/2025 at 2:40 p.m. LVN E said he worked some of the days when the medications were not documented as given or not given. He said if medications were not given it should be documented and the reason why it was not given. He said he usually works the 6:00am to 2:00pm shift and he usually give Resident #3 her medications he said he might have forgotten to document that the medication was given. He said was sure Resident #3 was given her medication. He said if there were no documentation to indicate if medications were given or not given it could be seen as neglect. He said if the resident did not get their medications they would take longer to get well. He said if the resident refused to take his/or her medications the physician, responsible party, DON or ADON should be notified. He said he will have to pay more attention, ensuring that when medications were given they were documented, and if medications were not given they should be documented and the reasons why they were not given. She said the thyroid medication was not given on his shift it was to be done on the night shift. Record review of the undated facility policy and procedures on PHYSICIAN'S ORDERS read in part . POLICY: It is the policy of this Facility that physician orders are maintained per state and federal regulations. RESPONSIBILITY: Medical Records Technician PROCEDURE: NOTE: Orders must be signed electronically within a timely manner. 676323 Page 6 of 7 676323 02/21/2025 The Crescent 11353 Sugar Park Lane Sugar Land, TX 77478

F 0755 3. Level of Harm - Minimal harm or potential for actual harm Physician orders include: a. Residents Affected - Some All medications b. Treatments e. Special medical procedures required for the safety and well being of the Patient f. Limitation of activities g. Others as necessary and appropriate 6. Medications, diets, therapy, or any treatment may not be administered to the Patient without a written order from the attending physician. 676323 Page 7 of 7