Inspection·January 20, 2023

F 0604 right side of the bed. Resident #58 said he did not know what the siderails were for. Level of Harm - Minimal harm or potential for actual harm Observations of Resident #58 and interview with CNA B on 01/18/2023 at 3:15PM, revealed Resident #58 lying in bed with no side rails in use. CNA B, when asked about Resident #58's siderail use, stated she generally uses siderails on all residents who have siderails on their bed and she engaged the siderails after putting the residents in bed to prevent them from falling. She stated she was not trained to not use siderails and that she is an agency nurse aide and is not hired through the facility. CNA B was observed to put up the right half siderail on Resident #58's bed. Residents Affected - Few Observations of Resident #58 and interview with CNA C on 01/18/2023 at 3:30PM, revealed CNA C observed Resident #58 in bed with right half siderail in use. CNA C stated Resident #58 did not fall that much but if he needed to be changed, he would typically fall out of his bed in an attempt to use the restroom. She stated she had seen the resident get up and walk before. She stated the right siderail would be engaged because that is the side the resident uses to leave his bed and the siderail would prevent him from falling. She stated only the right side should be up and if siderails on both the left and right side were in use at the same time, that would be considered a restraint which would need a physician's order. Observations of Resident #58 and interview with the DON on 01/18/23 at 04:10 PM, revealed the DON walked in Resident #58's room and saw him lying in bed with the half-length rails in use. She disengaged the side rails. She stated that the half-length bed rails should not have been engaged or used for anyone. She said she had seen some bed rails in use before due to agency nurses who needed re-education. She stated the facility staff knew not to use them because they impose a danger to the residents. She stated Resident #58 was a fall risk and tried often to get out of bed when he was wet. She stated the bed should stay low with a fall mat in place to stay prepared for his falls. She stated she had seen it herself how dangerous it can be for residents if bed rails are used. She said Resident #58 had only been assessed and approved for the use of quarter rails at the top of the bed to position himself. In an interview with the Corporate RN on 01/19/23 at 10:46 AM she said that they did not encourage bed rail use because it is a form of a restraint. She stated staff should have only used the half-length side rails only for positioning and disengaged them when ADL care was done. In a phone interview with CNA D on 01/19/2023 at 12:57PM, she stated she was an agency nurse aide who worked with Resident #58 for the first time on 01/172023 during the 6AM - 2PM shift. She stated she did not remember who Resident #58 was and whether she put up siderails for him. In a phone interview with RNA B on 01/19/2023 at 1:02PM, she stated she worked with CNA D on the 6AM - 2PM shift on 01/17/2023and was familiar with Resident #58. She stated his siderails were usually in use to keep him from falling out of the bed. She stated Resident #58 climbed out of his bed before and needed a fall mat and low bed because of it. She stated she had seen Resident #58's siderails in use before multiple times and would only engage the resident's siderails if she noticed that they were engaged already prior to providing care to the resident. She said she would disengage the siderails to get them out of the way for assisting him with feeding but re-engage the siderails when she was done. She stated she could not recall if she received training on the use of bed rails or which residents specifically needed them. In a phone interview with LVN A on 01/19/2023 at 2:09PM, LVN A said bed rails were not kept in use for resident #58, and the half siderails were only in use when the resident was being changed. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 2 of 10 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 01/20/2023 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)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she worked with Resident #58 on 01/17/2023 during the morning shift but never saw both of the half side rails in use while she did her rounds. She said an agency nurse aide who is not familiar with the facility worked with Resident #58 on that day, and she is not familiar with the facility. LVN A stated she had seen agency staff use half-length bed rails to prevent them from falling out of bed and has had to correct agency staff to not use the half-length bed rails but instead to do frequent rounds on the residents. She stated the danger of using half-length bed rails on a resident is that they could climb over the rail and fall or they could get caught in the side rail and hurt themselves. She stated she knew Resident #58 was a fall risk and would not know how to use a side rail. She said if the side rails were up, he would have the ability to climb over them. In an interview with the Administrator on 01/20/2023 at 11:00AM, she stated the facility uses many agency staff and they had to educate them on the use of bed rails. She stated half-length rails should not be used to keep residents in bed but they were only to be used for repositioning during ADL care. She stated she needed to change the strategy and ensure rounds are performed to ensure siderails were not in use. Record review of the facility's policy on Physical Restraints, dated October 2022, revealed, . The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms . The use of restraints is a measure of last resort to protect the safety of the resident or others and must not extend beyond the immediate episode Whenever restraint use is considered, the community should explain how the use of restraints treats the resident's medical symptoms and helps the resident attain or maintain his or her highest practicable level of physical or psychological well-being. The community also explains the potential negative outcomes of restraint use, including: . restraint use may constitute an accident hazard . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 3 of 10 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 01/20/2023 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)

F 0641 Ensure each resident receives an accurate assessment. 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 accurately assess each resident's status for 2 of 8 Residents (Resident #41 and #58) reviewed for assessment accuracy in that: Residents Affected - Few - Resident #41's Comprehensive MDS dated [DATE] sections for cognition and mood were not complete. - Resident #58's Comprehensive MDS dated [DATE] did not correctly assess his fall history. This failure placed residents at risk of not receiving the proper care and services due to inaccurate MDS assessments. Findings include : Record review of a face sheet dated 1/19/23 indicated Resident #41 was an [AGE] year-old male admitted on [DATE] with diagnoses of end stage renal disease, hypertensive chronic kidney disease with stage 5 (a medical condition in which a person's kidneys stop functioning on a permanent basis leading for a regular course of long-term dialysis), type 2 diabetes, allergic rhinitis, dependence on renal dialysis, Alzheimer's disease. Record Review of Resident #41's comprehensive MDS dated [DATE] revealed Section C, Cognitive Patterns and Section D Mood were not completed. During an observation and interview with Resident #41, on 1/18/23 at 9:15 a.m., he was in his room sitting on the edge of his bed alert and orientated to person, place, and time. He appeared content and pleasant to talk with. Resident #41 explained that he had kidney failure and he had dialysis Tuesday, Thursday and Saturday. He showed his right upper arm where his fistula was placed and explained how and when he self-administers his medications that were prescribed at the bedside. In an interview on 1/18/23 at 11:36 a.m. LVN A said Resident #41 had an order for certain medications to keep at his bedside. LVN A said Resident #41 was assessed for the ability to self-administer his medications. She said the resident is cognitively capable of taking his own medications. During an interview on 1/19/23 at 10:47 a.m. MDS nurse A said he was a corporate nurse (a nurse who work for the company or organization) but had been helping the MDS nurses at the nursing facility by assisting with resident's MDS and care plans. He said all IDT members have a section to complete in the MDS. He said nursing or the social worker typically completed a BIMS and a mood assessment and it was entered into the MDS by that department. During an interview on 1/19/23 at 10:48 a.m. MDS nurse B said she was a corporate nurse but was helping with residents' MDS and care planning. She said she assisted with completing Resident #41's MDS. She said it was the IDT's responsibility to make sure their section of the MDS assessment was completed. She said Resident #41's comprehensive MDS assessment Sections C (Cognitive Patterns) and D (Mood) were not completed because the assessment was not done within the 7 day look back period. She said if a section was not completed it would not trigger the MDS care areas. She said Resident #41 is very alert to his surroundings. Interview on 1/19/23 at 10:47 a.m. MDS nurse A said the facility followed RAI guidelines to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 4 of 10 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 01/20/2023 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)

F 0641 complete the MDS assessment. Level of Harm - Minimal harm or potential for actual harm Resident #58 Residents Affected - Few Record review of the face sheet for Resident #58 revealed a [AGE] year-old male admitted into the facility on [DATE] and diagnosed with Parkinson's disease, overactive bladder and muscle weakness. Record review of Resident #58's care plan revealed the resident had a behavior of placing himself on the floor and had actual falls on 5/9/2022, 5/13/2022, 6/8/2022, 6/9/2022, 7/4/2022, 7/18/2022, 7/27/2022, 8/1/2022, 11/5/2022, 12/30/2022 and 01/08/2023. Interventions included fall mat to the side of the bed, bed in lowest position and increased monitoring for fall precautions. Record review of the EHR revealed Resident #58 had an annual assessment performed on 08/31/2022 and a quarterly MDS assessment done on 12/01/2022. Record review of the facility incident log dated 08/31/2022 - 12/31/2022 revealed Resident #58 experienced falls on 11/5/2022, 11/14/2022 and 11/19/2022. Record review of Resident #58's MDS, dated [DATE], revealed in section J1800 which asked if the resident had experienced any falls since admission/entry or re-entry or prior assessment, the resident was coded to have not had any falls. In an interview with MDS Nurse B on 01/19/2023 at 10:23AM, she stated the MDS assessments should always be answered accurately as if affects the plan of care. She said, however, the IDT reviewed falls every morning and discussed interventions for the resident that way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 5 of 10 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 01/20/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 8 (Residents #41 ) Residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan that described Resident #41's medications that he was able to self-administer. This could place residents at risk of a medication error. Findings include: Record review of a face sheet dated 1/19/23 indicated Resident #41 was an [AGE] year-old male admitted on [DATE] with diagnoses of end stage renal disease, hypertensive chronic kidney disease with stage 5 (a medical condition in which a person's kidneys stop functioning on a permanent basis leading for a regular course of long-term dialysis), type 2 diabetes, allergic rhinitis, dependence on renal dialysis, Alzheimer's disease. Record Review of Resident #41's comprehensive MDS dated [DATE] revealed Section C, Cognitive Patterns was not completed. Resident #41's mental cognition was not assessed. Record review of the current Care Plan, dated 1/19/23, revealed no documentation about Resident #41's ability to self-administer some of his own medications. Record review of the Order Summary Report dated 1/19/23 revealed physician orders for Resident #41 to self-administer these medications: Flonase Suspension 50mcg (Fluticasone Propionate) 1 pump in both nostrils one time a day for allergic rhinitis. May have at the bedside. May self-administer. Order date 9/23/22. Hydrocortisone Cream 1% apply to right upper shoulder topically as needed for rash/ itching TID until resolved. May have at bedside. Order date 9/23/22. Lidopril Kit 2.5-2.5% (Lidocaine- Prilocaine) apply to left upper extremity fistula topically one time a day every Tuesday, Thursday, Saturday for pain. May keep at bedside and self-administer before dialysis. Order date 12/6/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 6 of 10 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 01/20/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Velphoro Tablet Chewable 500mg (Sucroferric Oxyhydroxide) give 2 tablets by mouth two times a day for end stage renal disease before meals. Resident may keep at bedside. Order date 12/12/22. During an observation and interview with Resident #41, on 1/18/23 at 9:15 a.m., he was in his room sitting on the edge of his bed alert and orientated to person, place, and time. Placed on the bedside table next to the resident was a small (Flonase) nasal allergy bottle medication in the opened manufacture box. He was asked about the prescribed nasal spray and said he used it daily because he had allergies. Resident #41 explained that he had kidney failure and he had dialysis Tuesday, Thursday and Saturday. He showed his right upper arm where his fistula (a connection that's made between an artery and a vein for dialysis access) was placed, then picked up the Lidopril and explained that he applied the medication on the days he went to dialysis. He said that he applied the cream to the fistula then wrapped it with Saran wrap because it would lessen the pain when the needle was inserted. Resident #41 explained he used Hydrocortisone cream on his arms because going to dialysis made him have itchy skin. Then he opened the nightstand table drawer and pulled out a prescribed bottle of Velphoro tablet chewable 500mg. He said he kept that medication at the bedside because it is supposed to be given close to his meals and the nurses could not always come in immediately during mealtime. In an interview on 1/18/23 at 11:36 a.m. LVN A said Resident #41 had an order for certain medications to keep at his bedside. She explained Resident #41 was competent in self-administration of those medications. LVN A said Resident #41 was assessed for the ability to self-administer his medications. During an interview on 1/18/23 at 3:45 p.m., the DON said Resident #41 had an order to self-administer some of his medications. She said he has other medication orders that the med aide gave him routinely. She said she was not aware Resident #41 did not have a care plan for self-administration of those medications. She said the MDS nurse should have written a care plan. The DON said Resident #41 had an assessment for self-administration which identified he was knowledgeable and capable of the meds he takes at his bedside. She said the resident could be at risk for a medication error if the IDT did not identify and review his ability to self-administrate his medications. During an interview on 1/19/23 at 10:47 a.m. MDS nurse A said he was a corporate nurse (a nurse who work for the company or organization) but had been helping the MDS nurses at the nursing facility. He said all the nursing staff are helping with making sure that the care plans are correct. During an interview on 1/19/23 at 10:48 a.m. MDS nurse B said she was a corporate nurse but was helping with residents' MDS and care planning. She said she assisted with completing Resident #41's MDS. She said it was the IDT's responsibility to make sure the care plans are complete, accurate and updated. She said Resident #41 should have had a plan of care for self-administration of medications and she did not know why the resident's care plan did not address this care issue. Record review of the facility's policy on Comprehensive Care Plans, dated February 2017, read in part .The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are defined in the comprehensive assessment An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing and mental and psychological needs is developed for each resident. The care plan will describe: the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The comprehensive care plan is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 7 of 10 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 01/20/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete prepared by an interdisciplinary team . other appropriate team members in disciplines as determined by the resident's needs . Record review of the facility's policy on Medication- Self-Administration dated 3/15/19, read in part . 4. Based on the self-administration review, a decision shall be made as to whether or not the resident is a candidate for self-administration. This shall be recorded on . addition to updating the plan of care . Event ID: Facility ID: 676350 If continuation sheet Page 8 of 10 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 01/20/2023 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #316) reviewed for urinary catheters in that: The facility failed to ensure Resident #316's urinary catheter bag was off the floor. This deficient practice could affect residents who had urinary catheters and result in trauma or urinary tract infections. Findings include: Review of Resident #316's face sheet, dated 1/19/23, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet diagnoses list included viral pneumonia (Primary, Admission), acute respiratory failure with hypoxia (low oxygen), (Secondary, admission from recent hospitalization). Further diagnoses included gastritis (inflammation of the stomach), esophagitis (inflammation of the esophagitis), gastrointestinal hemorrhage (a rupture in the intestinges), gastrostomy status (feeding tube), dementia. Review of Resident #316's quarterly MDS assessment, dated 12/01/22, revealed the resident had an indwelling catheter and urinary continence was not rated. Review of Resident #316's Nursing Admission/readmission Assessment, dated 01/16/23, revealed documentation the resident had an indwelling urinary catheter. Observation on 1/17/23 at 10:07 AM revealed Resident #316 was lying in bed at its lowest position. A urinary catheter drainage bag was hanging on the side of the bed frame with approximately 300 ml of yellow urine in the bag. The catheter bag and the tubing were touching the floor. Observation on 1/18/23 at 11:34 AM revealed Resident #316 was lying in bed at its lowest position. A urinary catheter bag and tubing were touching the floor. There was approximately 400 cc of yellow urine in the catheter bag. Interview on 1/18/23 at 11:36 AM revealed LVN B was informed of the catheter bag and she went to assess Resident 316's catheter. LVN B identified the resident recently returned from the hospital with a urinary catheter and there should have been a privacy bag on the catheter. Later interview with LVN B said she corrected the position of the catheter and placed a privacy bag over the catheter bag. Observation and interview on 1/18/23 at 2:36 PM, revealed Resident #316 lying in bed at the lowest position and the privacy bag and catheter tubing were touching the floor. LVN B was taken into the resident room to show her the catheter tubing and bag. LVN B said the tubing and privacy bag should not be touching the floor because it increases the risk for infection and accidents. She said it was all nursing staff responsibility to monitor the position of the drainage bag and the tubing. Interview on 1/19/23 at 10:50 AM revealed the Corporate Nurse said it was the nurse's and CNA's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 9 of 10 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 01/20/2023 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsibility to make sure that the catheter tubing is not touching the ground. She said the administrative staff also make rounds to resident rooms daily to check for things like urinary privacy bags and catheter bags/ tubing touching the floor. She said the resident was at risk for infection if the catheter bag was touching the floor. Interview on 1/19/23 at 2:10 PM revealed the DON said the nursing staff know that the catheter bag and tubing were supposed to be clipped onto the resident and the bed to prevent it from touching the floor. She said that she would do additional in-service in catheter care for all staff. She said the potential harm could be infection. Record review of the facility policy on incontinence and catheterization dated February 2017 read in part The community employs standard infection control practices in managing catheters and associated drainage system urinary tract infections . the facility employs standard infection control practices in managing catheters and associated drainage system . urinary incontinence requires that a resident incontinent of bladder receives appropriate treatment and services to prevent urinary tract infection . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 10 of 10