Health inspection·June 27, 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 observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one (Resident #81) out of eight residents reviewed for ADLs. Residents Affected - Few The facility failed to provide personal hygiene to Resident #81 which resulted in patches and dry flaky skin from below the knee to her feet . These deficient practices could place residents at risk of skin breakdown, and reduced feelings of self-worth. Findings included: Record review of Resident #81's face sheet dated 05/24/25 revealed a [AGE] year-old female was admitted on [DATE]. Resident #81 had diagnoses which included: fracture of the neck of left femur (a broken hip), hypertension (when the pressure in the blood vessels is too high), and diabetes mellitus (a disease of inadequate control of blood levels of glucose). Record review of Resident 81's quarterly MDS assessment, dated 05/27/25, revealed the BIMS score was 03 which indicated severely impaired cognition. Further review of the MDS revealed the resident needed extensive assistance with one on staff assist with ADL care. Record review of Resident #81's care plan initiated 02/25/25 and revision on 06/03/25 revealed the resident had an ADL self-care performance deficit related to CVA with hemiparesis. Intervention: bathing/shower: The resident was totally dependent on one staff to provide bath/shower and as necessary. Personal hygiene/oral care: The resident was totally dependent on one staff for personal hygiene and oral care. Record review of Resident #81's shower record on the POC from 05/29/25 through 06/21/25 revealed the resident had not missed any shower and bed bath. During an interview on 06/24/25 at 10:22 a.m., Resident #81 was sitting up in bed, and the head of the bed was at 45 degrees. Resident #81 said her skin from her lower legs to her feet was dry and itchy. During an observation on 06/24/25 at 10:30 a.m., revealed Resident #81's skin from below her knee to her feet was dry, patchy, and flaky when CNA B removed the resident's socks. Page 1 of 10 676337 676337 06/27/2025 Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 06/24/25 at 10:37 a.m., CNA B said Resident #81's skin was dry and flaky. CNA B said Resident #81's shower days were Tuesday, Thursday, and Saturday. CNA B said the aides are responsible for showering the resident and applying lotion to the resident's skin after showering and as needed. CNA B said if the aides did not apply lotion to Resident #81's skin, it could cause the resident's skin to be dry, which could cause skin breakdown. CNA B said the nurse monitors the aides throughout the shift. CNA B said she had an in-service on showing residents, and it included applying lotion to the resident's skin. During an interview on 06/25/25 at 10:30 a.m., LVN U said the aides were responsible for giving Resident #81 a shower and the aide should apply lotion after shower and as needed whenever the aide provided care for Resident #81. LVN U stated if the staff did not apply lotion or cream to Resident #81's skin, the resident's skin would often be dry and flaky, and it would break open. LVN U stated that the nurses monitored the aides throughout the shift, and the nurse manager monitored the nurses during their rounds. During an interview on 06/25/25 at 10:35 a.m., the ADON T stated that the aides are responsible for showering Resident #81 and applying lotion or cream to the resident's skin after showering and as needed to prevent the skin from becoming dry. The ADON T said if the aide did not apply lotion on Resident #81's skin, it could cause her skin to break down. The ADON T said the aides should have done a skills check-off before starting work on the floor, and nurses monitored the aides throughout the shift, while nurse managers monitored the nurses during rounding. During an interview on 07/26/25 at 7:27 a.m., the DON said the aides should apply lotion on Resident #81's skin after shower and as needed. The DON said the aides or nurses should apply lotion on Resident 81 #'s skin during care or whenever Resident #81's skin was dry. The DON said the nurses monitor the aides throughout the shift. She stated the ADONs monitor the nurses during random rounds. The DON said she had not done any in-service on skin integrity, but she may have done one in-service on ADL care. The DON stated that Resident #81's skin could be susceptible to some skin impairment if staff did not apply lotion or cream to the resident's skin. The DON said her expectation during training was the importance of keeping the skin moisturized to avoid skin tears and skin breakdown. She stated the nurse monitored the aides throughout the shift, and the nurse managers monitored the nurses. During an interview on 06/27/25 at 11:13 a.m., the Administrator said her expectation for the staff was to apply cream or lotion on the resident skin on shower days and as needed. She said the aides are supposed to apply moisturizer on residents on shower days and as needed. The Administrator said the aides had skills check on ADL but was unsure if there was a section on applying lotion. The Administrator said the nurse monitors the aides throughout the shift, and the nurse managers monitor the nurse during rounding. Record review of the undated facility policy on skin integrity management system read in part . CNA's will document skin observation each . Record review of the facility policy on ADL dated 5/26/23 read in part . policy explanation and compliance guidelines . #3 . a resident who is unable to carry out activities of daily will receive the necessary services to maintain .grooming . 676337 Page 2 of 10 676337 06/27/2025 Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision, in that: Residents Affected - Few CR #1 eloped from the facility on 6/21/25 after being let out of the building by the Receptionist. CR #1 was found by another staff member on the sidewalk near the carwash which was next door to the facility. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/21/25 and ended on 06/21/25. The facility corrected the non-compliance before the survey and investigation began on 06/24/25. The IJ template was sent to Administrator on 06/26/25 at 11:40a.m. This failure could place the residents with exit seeking behaviors at risk for injury or death. Findings included: Record review of CR #1 face sheet dated 06/25/35 revealed a [AGE] year-old male who admitted to the facility on [DATE] and discharged to a secure facility on 6/21/25. His diagnosis included: hemiplegia (severe weakness on side of the body) and hemiparesis (weakness affecting one side of the body, often the arm, leg, and sometimes the face) following cerebral infarction (part of the brain dies because it did not get enough blood or oxygen) affecting right dominant side, major depressive disorder(mood disorder that causes a feeling of sadness or loss of interest), atrial fibrillation(upper chambers of the heart beats very fast), and hypertension(when the pressure in the blood vessels is too high). Record review of CR #1 99 MDS assessment dated [DATE] revealed CR #1 was admitted to the facility on [DATE]. CR #1 was a admit. Record review of CR #'s initial baseline/advanced care plan dated 06/20/25 read in part . CR #1 required assistance with ADLs, and he was not at risk for elopement . Record review of CR #1's initial nursing evaluation dated 06/19/25 indicated he was alert to person and place and had difficulty expressing/pronouncing words. Record review of CR#1 BIMS assessment conducted twice on 06/21/25 revealed results were 0 out of 15 which indicated severe cognitive impairment. Record review of CR#1's BIMS assessment conducted on 06/21/25 result was 2 out of 15 which indicated severe cognition impairment. Record review of CR#1 initial wandering dated 06/19/25 25 indicated he was not a wandering risk. He used a manual wheelchair for ambulation. Record review of CR #1's nursing note dated 6/21/25 indicated the resident was noted outside the building by staff who was let out by the receptionist. The nurse brought the resident back in the facility and a head-to-toe assessment was done. There were no skin issues, and the facility started 1:1 676337 Page 3 of 10 676337 06/27/2025 Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091

F 0689 monitoring. A new order was received from the MD to transfer resident to a secure facility. Level of Harm - Immediate jeopardy to resident health or safety During an interview on 06/25/25 at 2:24 p.m., CNA B said she was across the street from the facility on break and saw CR# 1 outside of the facility gate by himself near the carwash. CNA B said CR #1 resisted returning to the facility. CNA B said she called the Weekend Supervisor and RN C for assistance in bringing CR # 1 back to the facility. CNA B said if she had not been at the store across the street on break, no one would have known that CR #1 had left the premises. Residents Affected - Few During an interview on 06/25/25 at 3:05p.m., RN C said she was CR#'s1 nurse on the day of the incident, and it was her first day working with CR # 1 on 6/21/25. RN C said she received a report from the previous nurse that CR #1 was a fall risk, chair-bound, and confused. RN C said CR#1 was sitting in his wheelchair by the nursing station, facing the front door of the facility, when she went down the 100 hall to check on another resident. RN C said the Weekend Supervisor called and told her that CR #1 was outside the facility premises, by the car wash. RN C said she went out to the car wash with the weekend supervisor and assisted CR #1 back to the facility. RN C said she did head to assessment, and CR #1 had no injuries. RN C said CR #1 could not be outside by himself because he was cognitively impaired, and he could have gotten kidnapped or gone into the road. During an interview on 06/25/25 at 4:07 p.m., R N said CR# 1 approached the front door and made sounds, but she did not understand him. R N said she assumed CR #1 wanted to go outside, and she opened the door for him and let him out unattended. She said she did not know if CR #1 could go out by himself and did not ask other staff members. She said he might have exited the parking lot gate when a car entered the facility. R N said she was not aware of the wandering/elopement binder at the reception desk until after the elopement when the administrator brought the wandering and elopement binder to the reception desk. R N said she was under the assumption that residents sign out when they want to leave the facility premises, not when they want to sit outside the front door of the facility. That was why she let CR #1 out the door without him signing out. R N said she no longer work for the facility and her last day was on 06/21/25. During an interview on 06/25/25 at 4:47 p.m., the Administrator said R N told her she let CR #1 out the front door without checking the elopement binder or asking the nurse to make sure CR #1 could go outside by himself. The Administrator stated that R N said she let CR #1 out of the facility through the front door around 9:15 a.m. but was unsure of the exact time. The Administrator said the DON called her and notified her about CR#1 elopement and she came to the facility about 9:45 a.m. When the surveyor asked the Administrator what could have happened to CR #1 when he went outside the facility premises, the Administrator responded that CR #1 could have seen his loved ones while at the care wash. During an interview on 06/25/25 at 4:50 p.m., The DON said CR #1's BIMS score was 2 out of 15 (which indicated severe cognitive impairment). She said he should not have gone outside to sit by himself because he was cognitively impaired. The DON said residents who leave the building must sign out, but it would not have been appropriate for CR #1 to sign out because he had an impaired memory. The DON said R N should have asked a nurse or checked the wandering and elopement binder at the receptionist's desk before letting CR# I out of the building. The DON said anything could have happened to CR #1 when he was by the car wash. During an interview on 06/25/25 at 6:10 p.m., CR #1's RP said the facility called and notified her that CR #1 had left the facility premises, and the staff assisted him back to the facility. CR #1's RP stated that CR #1 was anxious and confused due to his new environment, and the facility should 676337 Page 4 of 10 676337 06/27/2025 Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091

F 0689 not have allowed him outside the door. Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility incident and accident dated 08/15/22 read in part incident is defined as an occurrence or situation that was not consistent with the routine care of a resident . Residents Affected - Few Record review of the facility elopement and wandering resident read in part . elopement occurs when a resident leaves the premises or a safe area without authorization .#4. Monitoring and managing residents at risk for elopement or unsafe wandering .4a. resident will be assessed for risk for elopement or unsafe wandering upon admission and throughout their stay by interdisciplinary care team .4c. interventions to increase staff awareness of the resident's risk, modify the resident's behavior 4d. adequate supervision will be provided to help prevent accidents or elopements. Record review of the corrective actions' facility implemented facility beginning on 06/21/25. The facility had AdHoc QAPI Meeting was held on 06/21/25 and it was attendees were the Medical Direction, The Administrator, and DON. The summary and plan: indicated CR #1 observed on the side work outside the facility gate. Staff member who went on break a t a store across the street from the facility approached CR #1 and attempted to redirect him back to the facility. One of the CNAs called ADON who then sent additional staff to assist with redirecting CR #1 back inside the facility. Plan: The facility has an elopement book with resident pictures and resident consent forms for resident who are able to sign out the facility. All new residents will receive BIMS assessment and elopement/wandering assessment. All current facility staff have been in serviced on wandering resident and elopement. All new staff will be in serviced upon hire regarding wandering and elopement. Performance Improvement Plan: Issue: CR#1 left the facility premises and was outside the gate of the facility, by facility staff and brought back without incidence. The following was completed on 06/21/25: CR #1 was returned to the facility with 15 minutes by staff. Head count. No concerns identified Medical Director notified MD and RP notified Head to toe evaluation assessment completed for CR #1 CR #1 transferred to a facility with secured unit Immediate interventions on 06/21/25 and 06/22/25 Wandering evaluations completed for all facility residents to identify other residents at risk for elopement Elopement/wandering binder reviewed and updated as indicated Resident current BIMS score reviewed to confirm residents able to leave the facility unsupervised. 676337 Page 5 of 10 676337 06/27/2025 Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091

F 0689 Book reviewed and updated as indicated Level of Harm - Immediate jeopardy to resident health or safety Exit doors checked for securement and function of alarms Residents Affected - Few Elopement drills completed all shifts Exit gate checked for proper function Reeducation on 06/21/25: : (In service on elopement) The Administrator and/ or designee reeducated facility staff on the facility's Elopement and Wandering procedures, as well as Abuse and Neglect. Reeducation included identification of current residents who are elopement/ wandering risk and methods of identifying new elopement/ wandering risk, as well as identifying residents who can sign themselves out and leave the facility unsupervised. Pre and posttest were completed by staff to validate their understanding of the processes. Systemic Changes: 06/22/25, Education on Elopement and Wandering, to include pre/ posttest on first day of hire/ rehire for facility staff. Monitoring Outcomes: Effective 06/22/25, the Administrator and/ or designee will validate staff's understanding of elopement procedures by quizzing staff and completing questionnaires for random staff from all disciplines, all shifts including receptionist weekly for four weeks, then monthly for two months. The Administrator and/ or designee will conduct elopement drills on all shifts monthly for three months. Record review of the facility in-service dated 06/21/25 revealed staff were in serviced on resident leaving facility/elopement and wandering. Residents have the right to sign themselves out of the facility on pass for up to 72 hours at a time. Residents must sign out using the sign out book. There is a sign out book and an elopement book located at the receptionist desk and the nurse's station. In the elopement book there are pictures of residents who are a wandering risk and if they are going towards a door nursing staff must be notified immediately to redirect the resident. The Administrator and DON must be notified as well for any elopement risks. There are also consent forms located in the elopement book for all residents who are able to sign themselves out. If the resident does NOT have a signed consent form located in the book, you must make sure the resident stays within eyesight during the entire exit attempt and notify any facility staff currently working to assist also the DON and Administrator must be notified. Failure to follow the company protocol will result in disciplinary action, up to and including termination. record review of the facility elopement [NAME] revealed the facility completed wandering evaluation on CR #1 and all the resident in the facility after the elopement on 06/21/25. Record review of the facility incident binder revealed the facility completed BIMS for CR #1 and all the resident in the facility on 06/21/25. During an interview on 06/27/25 between 10:25 a.m. and 10:45 a.m., Resident #51 stated that the facility staff did not allow him to go out the front door by himself, but he could go through the back door, which required a code. Resident #51 said the staff would let him out because it was fenced in. Residents #25, #72, #77, #80, and #298 said they could sign out and go out through the front door 676337 Page 6 of 10 676337 06/27/2025 Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and sit on the porch or leave the facility, but they have to sign out and sign back in when they entered the facility. During interview on 06/ 25/25 between 2:02 p.m. through 5:56 p.m. LVN R, R N, R G, RN C, CNA L, LVN U, CNA S, CNA B and on 06/26/25 between 9:58 a.m., and 4:30 p.m., LVN N, LVNK, LVN M, CNA K, CNA I, CNA J, CNA P, ADON, Office Manager, and HR were able to state they had a service on wandering and elopement. They said the facility had two binders: one for residents who could sign out and the other for those who could not sign out by themselves (the wandering/elopement binder). They said all residents must sign out before leaving from the front door. They said if a staff member was unsure whether a resident could leave through the front door, then the staff member must review the binders and ask the nurse before letting any resident out the front door. They said they had to lay eyes on their residents during rounds and monitor any residents who wander. They said if the staff could not find any resident, they had to report to the nurse, and the nurse would call Code Pink and notify management. The staff would start by searching all parts of the building and outside the building. The administrator would be the contact person for the facility. During an interview on 06/25/25 at 5:10 p.m., the Administrator said the DON notified her, and when she came to the facility, they (the medical director and DON) had QAPI. At the same time, RN C assessed CR #1 and placed him on 1:1 care until he was transferred to another facility around 4:30 p.m. on 06/21/25. The Administrator stated that the staff received in-person training on wandering and elopement, and electronic training was sent to all staff. No staff member was allowed to work unless they had completed the in-person training on wandering and elopement. The Administrator stated that the in-service was based on the facility's policy regarding accidents, supervision, and wandering/elopement. The Administrator stated that they had updated the two binders: one for elopement/wandering, which included pictures of the resident, and the other binder for residents who could sign out, containing the necessary consent forms. She said the binders are kept at the nursing station and the receptionist's desk. She also said R N(receptionist) no longer works for the facility. During an interview on 06/25/26 at 5:30 p.m., the DON said the weekend supervisor notified that CR #1 had left the facility premises, and she notified the administrator. The DON said she came to the facility on [DATE] and had a QAPI meeting, and then she started head count for all the residents in the facility. She said CR #1 was assessed and placed on 1:1 until he was transferred to a secured facility. The DON stated that the IDT team assisted with reviewing all resident BIMS and elopement risk assessments and updated the elopement binder and sign-out binder accordingly. The DON said she placed One set of binders at the nursing station while the other at the receptionist's desk. The DON stated that she notified CR #1's RP, CR #1's physician and risk management. Observation on 07/27/ at 2:30 p.m., revealed the alarm on the door would go off, the receptionist had the remote control for the door. Observation on 07/27 at 2:45 p.m., revealed regular wheelchair would not trigger the electronic gate to open. 676337 Page 7 of 10 676337 06/27/2025 Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091

F 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was not five percent or greater. The facility had a medication error rate of 16% based on 4 errors out of 25 opportunities which involved 3 of 5 residents (Residents #4, #63 and #89) and 3 of 5 staff (RN C, MA A, and LVN O) reviewed for medication administration.1. RN C crushed and administered enteric coated Aspirin 81 mg (a formulation of aspirin, that should not be crushed, that has a special coating to prevent it from dissolving in the stomach) to Resident #4 on 6/25/25.2. MA A administered Sennosides instead of Sennosides with Docusate according to physician orders and failed to administer the prescribed amount of Clearlax (Miralax/Polyethylene Glycol 3350) to Resident #63 on 6/25/25. 3. LVN O failed to set Resident #89's IV Zosyn (a combination of two antibiotics that treat bacterial infections) to the correct flow rate according to the pharmacy label on 6/25/25.These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects and decline in health. Findings include: 1. Record review of Resident #4's face sheet, dated 6/27/25, revealed an [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnosis included heart failure, hypertension (high blood pressure), chest pain, and chronic obstructive pulmonary disease.Record review of Resident #4's quarterly MDS assessment, dated 5/30/25, revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #4's care plan dated 3/4/25 revealed she had a history of congestive heart failure. Interventions were to administer cardiac medications as ordered. Monitor, document, and report effectiveness, adverse reactions, and side effects. Aspirin.Record review of Resident #4's Physician orders for June 2025 revealed an order for Aspirin chewable 81 mg give 1 tablet via g-tube one time a day for reduce risk of heart attack, stroke, order date 5/1/25.In an observation on 6/25/25 at 8:39 a.m. revealed RN C prepared Resident #4's medication for administration via g-tube. She prepared 7 medications which included enteric coated Aspirin 81 mg. RN C crushed the enteric coated aspirin along with the other medications and administered it to Resident #4 via g-tube.In an interview on 6/25/25 at 9:36 a.m., RN C said enteric coated formulations could not be crushed because the medication would not work the way it was supposed to. She said she normally reviewed the resident name, medication dose and name but missed where the Aspirin bottle read enteric coated. She said there was no risk to the resident. In an interview and observation on 6/26/25 at 2:20 p.m. the DON said staff could not crush enteric coated formulations because the coating could cause clogging (of the g-tube). She said staff were made aware of which medications not to crush by the list located in the medication book. Observation of the do not crush list revealed enteric coated Aspirin was listed on it.2. Record review of Resident #63's face sheet, dated 6/27/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included constipation, nontraumatic intracerebral hemorrhage (a type of stroke characterized by bleeding within the brain tissue), and hemiplegia (a complete paralysis of one side of the body) and hemiparesis (weakness on one side) following cerebral infarction (stroke) affecting right dominant side.Record review of Resident #63's quarterly MDS assessment, dated 3/21/25, revealed a BIMS score of 6 out of 15, which indicated severe cognitive impairment. She needed assistance from staff with ADL care.Record review of Resident #63's Physician orders for June 2025 revealed orders for: Sennosides - Docusate 8.6 mg - 50 mg give 1 tablet by mouth two times a day related to constipation, order date 1/7/25;Miralax Oral Powder 17 gm/scoop (Polyethylene Glycol 3350) give 1 scoop by mouth one time a day related to constipation, order date 1/7/25.In an observation on 6/25/25 at 9:41 a.m. revealed MA A prepared Resident #63's medication for administration. He prepared Senna 8.6 mg (without Residents Affected - Some 676337 Page 8 of 10 676337 06/27/2025 Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Docusate), Clearlax 3350 7.5 mL, and 7 additional medications. While preparing the Clearlax 3350, MA A did not use the provided 17-gram measuring cup but poured the powder into a medicine cup which equaled approximately 7.5 mL. He mixed the powder with water and administered all prepared medications to Resident #63.In an interview on 6/25/25 at 10:08 a.m. MA A said Senna 8.6 mg (without Docusate) was the only Senna on his medication cart. He said the only difference between the medication administered and the medication ordered was the 50 mg and said the medications were the same. MA A said Resident #63's Clearlax order indicated to administer 1 capful. Observation of the Clearlax (Polyethylene Glycol 3350) bottle read, 1(7) g. cap filled to line. He said he administered approximately 5 mL of Clearlax powder to Resident #63 which was not a capful. He said he administered that amount because that was all he had available. He said he normally used the provided measuring cap to measure but did not because the amount of remaining powder was so low. In an interview on 6/26/25 at 2:22 p.m. the DON said Senna Plus (with Docusate) was more effective than Senna (without Docusate) because there was more active ingredient to help with the bowel. She said Senna and Senna Plus were not the same medication and the difference was the Docusate (stool softener). She said nursing staff should use the provided purple top to measure Clearlax to give the correct dose for effectiveness. She said medication aides should communicate with their nurses if they do not understand. She said the facility had a policy in place to follow the 6 rights of medication which included the right resident, time, dose, form, route, and medication.3. Record review of Resident #89's face sheet, dated 6/27/25, revealed a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #89 had diagnoses which included osteomyelitis (a serious bone infection that can occur due to bacteria or fungi), partial traumatic amputation of right foot (some soft-tissue connection remains), type 2 diabetes, dementia, and moderate protein-calorie malnutrition.Record review of Resident #89's 5-day scheduled MDS assessment, dated 6/15/25, revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. She required some assistance from staff with ADL care. The MDS revealed she had midline IV access and received IV antibiotics.Record review of Resident #89's Order Audit Report for June 2025 revealed an order for Piperacillin Sod Tazobactam solution (Zosyn) 3-0.375 gm use 3.375 gram intravenously three times a day for acute osteomyelitis, order date 6/20/25. Order Supply Summary. Medication/Supply and Directions: Zosyn 3.375 gm/50 mL galaxy infuse contents of one bag intravenously over 30 minutes at a rate of 100 mL/hr three times daily.In an observation and interview on 6/25/25 at 4:03 p.m., LVN O flushed Resident #89's PICC lumens and hung the Zosyn 3.375 gm/50 mL bag at a rate of 125 mL/hr. Observation of the Zosyn pharmacy label read, Infuse contents of one bag intravenously over 30 minutes at a rate of 100 mL/hr three times daily. LVN O said she normally set rates at 125 mL/hr when the order indicated for the IV to run over 30 minutes. She said the pharmacy label indicated the rate should be at 100 mL, but she set the rate at 125 mL. LVN O entered Resident #89's and adjusted the rate. She said she normally checked the resident's name, medication, time, strength, and verified the IV bag alongside the order. She said if the rate was set higher, the medication would be administered a little quicker.In an interview on 6/26/25 at 2:35 p.m. the DON said the flow rate was located on the IV bag and on the order in the computer system. She said the IV should be set at the rate provided for efficacy. She said there could be side effects if not given according to the specified rate.In an interview on 6/27/25 at 11:10 a.m. the Administrator said she expected nursing staff to follow the MD order when passing medications for accuracy.Record review of the facility's undated Medications Not To Be Crushed revealed Aspirin EC was listed on it.Record review of the facility's Medication Administration policy dated 10/24/22 read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as 676337 Page 9 of 10 676337 06/27/2025 Houston Heights Nursing and Rehabilitation Center 6920 W T.C. Jester Blvd Houston, TX 77091

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. 14. Administer medication as ordered in accordance with manufacturer specifications. c. Crush medications as ordered. Do not crush medications with do not crush instructions. Do Not Crush Medications: Enteric coated. 676337 Page 10 of 10