Health inspection·October 28, 2021

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 observation, interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASRR for 1of 4 residents, (Residents # 86) reviewed for PASRR Level 1 screenings. Residents Affected - Few The facility did not send the correct PASRR Level 1 (PL1) screening to the local authority for Residents #86. This failure could place residents with positive PASRR at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental and psychosocial well-being. Findings included: Record review of Resident #86's face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old. Her admission diagnoses included: bipolar disorder (mental health disorder that cause extreme mood swings). Record review of Resident #86's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 03 out of 15 indicating severe cognitive impairment. Review of Section I Active Diagnoses on the MDS assessment revealed the resident was coded for bipolar disorder. Record review of Resident # 86's PASRR Level 1 Screening signed on 2/25/21 and 8/19/21 revealed in Section C, C0100 Mental Illness, the question Is there evidence or an indicator this is an individual that has a Mental Illness?, 0 indicating No was entered into the box. Record review of Resident #86's undated care plan revealed no care plan to address bipolar disorder. Further record review of Resident #86's care plan undated revealed: Focus: I have memory problems; I am at risk for further decline in my cognition that may affect my ability to communicate my needs/wants and affect my ability in caring for myself/participate in my own care. Goal: I will maintain my current level of cognitive functioning and ability to participate in my care without further decline or dependency on others through my next review date. Interventions: Notify my physician for changes in my ability to communicate as indicated. Record review of Resident # 86's MAR dated October 2021 revealed no Physician Order for Bipolar Disorder medication. Observation and interview on 10/28/21 at 9:35 AM revealed Resident # 86 laid in bed staring up at Page 1 of 4 676350 676350 10/28/2021 The Heights of Tomball 27840 Johnson Road Tomball, TX 77375

F 0645 the ceiling. She was unable to answer any questions. Level of Harm - Minimal harm or potential for actual harm In a record review and interview on 10/28/21 at 10:00 AM with the MDS Coordinator after she reviewed Resident # 86's completed PASRR Level 1 Screening and diagnoses, she said Resident #86's PASRR was coded incorrectly. She said Resident #86 had a diagnosis of mental disorder and Resident #86 was not coded correctly for it. The MDS Coordinator stated the hospital completed the PL1, but the Social Worker was responsible for reviewing the PASRR's and making corrections when needed. She said they should have caught the error during the quarterly care plan review because the resident had to be assessed for services that would help with her level of functioning. Residents Affected - Few Interview on 10/28/21 at 10:15 AM the Social Worker said Resident # 86's PASRR was coded incorrectly, she said the MDS coordinator was responsible for confirming information on the PASRR. The Social Worker said they had to send a referral to [NAME] County whenever they get a positive PASRR so they can do an assessment at the facility. She said she was not sure why no one caught the incorrect PASRR code for Resident #86, but it should have been corrected when she was admitted because of the services she might have been entitled to and could have helped with her level of functioning if needed. In an interview on 10/28/21 at 10:33 AM the DON said when residents are admitted to the facility they had to meet their needs and get the PL1 from the facility where they had been discharged from. The DON said the MDS Coordinator was responsible for following up on PASRR screenings. She said she was not sure why there was a gap in services, but she was going to make sure they addressed it going forward. The DON said the risk of not having a PASRR screening coded correctly is that the resident would not receive services to help with their level of functioning. Interview on 10/28/21 at 10:42 AM the Administrator said they are working on a process for identifying residents who need PASRR services. Record review and interview on 10/28/21 10:52 AM the Social Worker said there was no facility policy for PASRR Screening the facility uses the State Guideline. The pathway read in part; Use this pathway for a resident who has or may have a serious Mental Disorder (MD), Intellectual Disability (ID) or a Related Condition to determine if facility practices are in place to identify residents with one of these conditions and to determine if Level 1 PASRR screening has been conducted and referrals have been made to the appropriate state- designated authority for Level II PASRR evaluation and determination . 676350 Page 2 of 4 676350 10/28/2021 The Heights of Tomball 27840 Johnson Road Tomball, TX 77375

F 0760 Ensure that residents are free from significant medication errors. 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 were free of significant medications errors for one of four residents (Resident #26) reviewed for medications, in that; Residents Affected - Few Med Aide B crushed and administered Resident #26's Potassium Chloride ER 10 mEq medication without MD order to crush the tablet. This failure could place residents at risk for adverse consequences which could cause depleted potassium levels. Findings included: Record review of the facility face sheet revealed Resident #26 was admitted to the facility on [DATE] with a readmission on [DATE]. She was [AGE] years old. Her diagnoses included in part; cerebral infarction (decreased blood flow to brain), chronic atrial fibrillation (irregular, rapid heart rate), heart failure (heart unable to pump blood well), and presence of cardiac pacemaker (small device implanted in chest to help control heartbeat), Dysphagia (difficulty swallowing foods or liquids). Record review of Resident #26's admission MDS assessment, dated 10/13/21 revealed Resident #26 required 1-2-person assistance with her activities of daily living, which included: bathing/showering, dressing, grooming, personal hygiene, toileting, medication administration and mobility. Record review of Resident #26's Order Summary Report (Physician Orders) revealed in part; -10/27/2021 Potassium Chloride Extended Release Tablet 10 mEq, give one tablet by mouth one time a day for Hypokalemia. Record review of Resident #26's MAR dated October 2021 revealed order for Potassium Chloride Extended Release Tablet 10 mEq was administered daily. Record review of Resident #26's Order Summary Report, dated October 2021, revealed May open/crush medications as allowed by Physicians' Desk Reference (PDR) Guidelines-may give in food and/or liquids. Observation and interview on 10/27/21 at 10:57 AM during medication administration revealed Med Aide B Crushed Potassium Chloride Extended Release 10 mEq tablet, poured the contents into a 30-cc cup, added vanilla pudding, stirred and administered the medication to Resident # 26. Med Aide B stated There are MD orders to crush all medications for Resident #26 except her gel capsules. Med Aide B further said that she needed to crush Resident #26's Potassium Chloride Extended Release tablet because Resident #26 was not able to swallow the medication whole. In an interview on 10/27/21 at 1:09 PM the DON said she was not aware that Resident #26's Potassium Chloride Extended Release 10 meq tablet was being crushed. She said Potassium Chloride Extended Release should never be crushed because the risk was it could cause decreased or increased effects of the Potassium medication that could also affect the cardiac (heart) function. The DON said we must obtain a different formulation order if Resident #26 was unable to swallow the whole pill. She said had to do some re-education about the Do Not Crush Medication list with the nurses. 676350 Page 3 of 4 676350 10/28/2021 The Heights of Tomball 27840 Johnson Road Tomball, TX 77375

F 0760 Record review of Resident #26's telephone orders dated 10/27/21 revealed in part; Level of Harm - Minimal harm or potential for actual harm - .Discontinued orders of Potassium tablets and start Potassium liquid 20meq/15ml give 7.5 to equal 10meq daily. Residents Affected - Few Record review of Drugs.com read in part . Uses of Potassium Chloride Extended-Release Tablets: It is used to treat or prevent low potassium levels. Swallow whole. Do not chew, break or crush. Record review of the facility's pharmacy Common Oral Dosage Forms That Should Not Be Crushed document undated revealed Potassium Chloride Extended Release was on the list of medications not to crush. Record review of the facility's policy with title Medication Administration undated revealed in part; . e. Check the Do Not Crush list before crushing medications. Direct specific questions to the pharmacist. If necessary, contact the ordering physician for a change to a different route of administration when the medication cannot be crushed. 676350 Page 4 of 4