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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 676350 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Tomball 27840 Johnson Road Tomball, TX 77375 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)