Health inspection·May 26, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview and record review, the facility failed to ensure residents were safe from accidents and hazards for 1 of 2 sampled residents (Resident #7), in that: CNA G and CNA L was observed performing a 2-person assist transfer using a gait belt on Resident #7 who required a transfer by mechanical lift per his care plan. This failure places residents at risk of physical harm and injury. Findings included: Record review of Resident #7's face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE], and diagnosed with muscle weakness and cerebral palsy, which is a disorder that causes problems with movement, balance and posture. Record review of Resident #7's care plan, dated 05/26/2023, revealed the resident required 2-person assistance with the mechanical lift, initiated 08/05/2022. Record review of Resident #7's MDS, dated [DATE], revealed the resident had a BIMS score of 00, indicating resident's cognition was severely not intact. The MDS also revealed the resident needed extensive assistance for transfers. In an interview with Resident #7 on 05/25/2023 at 11:20AM, he stated they did not always use the mechanical lift to transfer him, but sometimes they used the sit-to-stand mechanical lift or would be lifted by two aides to be transferred from his bed to his chair. Observations and interviews on 05/26/23 at 10:18AM, revealed Resident #7 was transferred from his bed to the shower chair by CNA G and CNA L, with use of a gait belt. CNA D held the shower chair steady from behind during the transfer. CNA G stated the Resident #7 preferred being transferred by the mechanical lift but usually transferred into the shower chair using a gait belt. CNA L agreed with CNA G's statement and said that was how Resident #7 transferred for showers. In an interview with CNA L on 05/26/2023 at 11:23AM, she stated she knew Resident #7 was to be transferred using the mechanical lift, but CNA G, who has worked at the facility longer than her, took charge and insisted it would be easier to transfer the resident to the shower chair using a gait belt (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 2 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 05/26/2023 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)