Health inspection·August 30, 2023

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's undated Completed Physician Orders revealed an order to discontinue the IV line to right upper arm, ABT completed. The date ordered and completed was on 08/29/2023 at 12:30 PM, after the facility was notified by the surveyor on 08/29/2023 at 10:40 AM that Resident #1 had an IV line in his arm and the date on the dressing was 08/17. Record review of Resident #1's MAR/TAR/LNR for August 2023 revealed there was no scheduled dressing change for the PICC line. Further review revealed there was no scheduled saline flushes after 08/25/2023. Observations and interview on 08/29/2023 at 10:36 AM revealed Resident #1 lying in bed. The resident was cleanly dressed in no immediate distress with an IV site to his right upper arm. The transparent IV dressing was intact. The dressing was dated 08/17. There was a Biopatch Protective Disc over the IV insertion site. There was a small pocket of air and a small amount of dark red blood at the bottom edge of the Biopatch and blood alongside a small section of the tubing. Resident #1 stated the IV was placed while in hospital on the same date written on the dressing. Resident #1 stated the IV had not been used in maybe 3 days and he did not know when it was last flushed. He denied any pain. In an interview on 08/29/2023 at 4:00 PM, LVN E stated if a PICC line was not in use it should be flushed every shift and there should be an order for this. LVN E stated the reason for flushing was to decrease blood clotting in the catheter and if not flushed the risk to the resident would be an infiltration and increased chance of infection. In an interview on 08/29/2023 at 4:30 PM, the DNS stated Resident #1's PICC line was not being used and the NP was at the facility on 08/28/2023 and did not get the order in to discontinue the PICC. The DNS stated if it was not documented that the nurses reached out to the NP then it was not done. The DNS stated Resident #1's PICC line dressing should have been changed, if it was not documented then it was not done. The DNS stated she expected that the nurses should have at least called her for guidance. The DNS stated the management team had a long list of residents with IV's and IP also had the same list, so the team was aware of Resident #1's PICC line, She stated IV's should be discontinued when no longer needed and should not be left in too long d/t chance of infection. In an interview on 08/30/2023 at 12:30 PM, LVN A stated Resident #1 technically did not need a dressing change d/t the antibiotic order was completed and the PICC should have been discontinued. She stated it should be the ADNS and DNS to monitor for the follow up but sometimes things were just not caught. She stated the completion of Resident #1's IV antibiotics should have come up in the IDT meetings. She stated that the IP had already conducted nursing in-service and training on the importance of maintaining the IV. In an interview on 08/30/2023 at 1:05 PM, The ADNS stated Resident #1's IV dressing should have been changed on the last day of antibiotics which was 8/25/2023. She stated the nurse should have contacted the provider to see if additional orders were needed. She stated that normally the orders would be double checked after the end of the antibiotic treatment. She stated completion of the course of IV antibiotics would have been discussed in clinical meetings the next morning and again in the afternoon end of day meeting. The ADNS stated she did not know why it got missed. In an interview on 08/30/2023 at 1:30 PM, LVN C confirmed her initials on the MAR and stated she gave Resident #1 the last dose of IV Ceftriaxone on 08/25/2023. She said she did not call the MD to notify that the course of antibiotic was completed, she would have charted this if she did. LVN C stated on Sunday 8/27/2023 they were waiting for the doctor to call back. She stated the person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 2 of 14 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 08/30/2023 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible would be the nurse assigned to the resident on Sunday but that it was a very busy then and probably got missed. LVN C stated she would have been the one to flush Resident #1's catheter with normal saline on Saturday 8/26/2023 and Sunday 8/27/2023 because that was what was normally done do to keep it from clotting and that was her weekend to work. She stated she did flush the catheter on that weekend. She stated the flush orders were in the MAR. When LVN C looked at the MAR again, LVN C stated she was sure there was a flush order and said she mistook the normal saline order that ended on 08/25/2023 for a flush order to keep the catheter from clotting after the antibiotics were completed. She said she would need an MD order for the flush if the catheter was not being used. In an interview on 08/30/2023 at 5:00 PM, the DNS was asked if an MD order for normal saline flush was needed for a PICC line that was not being used, she said everything done requires an MD order. The DNS stated best practice for LVN C would have been to call the MD to clarify orders after she flushed Resident #1's PICC line with normal saline. She stated she would expect the nurse to call the DNS if the MD did not return the call. Record review of LVN C's Competency Assessment checklist, Guidelines for Preventing Intravenous Catheter-Related Infections signed by LVN C and the trainer/ DCE on 08/21/2023 revealed LVN C demonstrated and met all the goals. Record review of the DCE's Competency Assessment checklist, Guidelines for Preventing Intravenous Catheter-Related Infections signed by the DCE and the DNS on 06/24/2022 revealed DCE demonstrated and met all the goals. Record review of the facility's policy and procedure for read in part: Competency Assessment, Guidelines for Preventing Intravenous Catheter-Related Infections, revised August 2014 read in part: A) Purpose-The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous catheters. B) General Guidelines, 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: c. - appropriate infection control measures to prevent IV catheter-related infections.Overview of CRI (catheter related infections) 1. Potential risk factors associated with central venous access device (CVAD) and infusion related infections include: .c. multi-lumen catheters .Catheter Site Dressing Regimens, 1. Change initial dressing after catheter placement within 24 hours .4. Change TSM (Transparent, semi permeable membrane) dressing on CVAD (Central Venous Access Device) every 5-7 days or PRN if damp, loosened or visibly soiled. This does not require a physician's order .D) Documentation - The following information should be recorded in the resident's medical record: 1. Objective information regarding appearance of insertion site, catheter and dressing .2. Any interventions that were done (dressing change, cultures, etc.) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 3 of 14 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 08/30/2023 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 administer parenteral fluids consistent with professional standards of practice and care plans for 1 of 3 residents (Resident #1) reviewed for parenteral IV antibiotic care and services through a PICC therapy. Residents Affected - Few - The facility failed to provide care or dressing changes to Resident #1's IV catheter site from 08/19/2023 to 08/29/2023. This failure could place residents at risk for infection, pain, and hospitalization. Findings included: Record review of Resident #1's Face Sheet dated 08/29/2023 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include cellulitis (skin infection) of the left lower limb, diabetic peripheral angiopathy (disease of the blood vessels because of unregulated diabetes), proteus mirabilis (microorganism causing infection), heart disease, local infection of the skin and peripheral vascular disease (a blood circulation disorder). Record review of Resident #1's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, he required extensive assistance with bed mobility and toilet use. He required limited assistance with transfers, dressing and personal hygiene. He was occasionally incontinent of bladder and always continent of bowel. He had infection of the foot and diabetic foot ulcers. Record review of Resident #1's Care Plan last reviewed on 08/23/2023 revealed Focus-at risk for skin injury-new or worsening skin condition. Actual skin issues: left lower leg Cellulitis, left leg ulcers, both lower leg Venous statis (congestion and slowing of circulation in veins). Goal-skin injury will resolve without associated complications through the review date. Focus- at risk for infection or recurrent/chronic infection r/t compromised medical condition. Goal-will be free from S/S of infection and any complications r/t infection through the review date. Interventions included-administer medications and/or antibiotics as per MD orders. Doxycycline until 8/26/2023 and Ceftriaxone 2 gm until 08/26/2023 for left leg cellulitis. Focus-risk for complications associated with intravenous therapy. Goal-will be free from complications associated with IV placement through the next review date. Interventions included-administer medications and/or flushes as ordered by MD. Change dressing to IV access site as ordered. Frequent monitor/check IV access site upon each care encounter, look for s/s of infection. Record review of Resident #1's undated Completed Physician Orders revealed an order to monitor right upper arm IV-Line for S/S of infection every shift for 7 days, start date 08/19/2023 and end date 08/26/2023. An order for Ceftriaxone Sodium Solution Reconstituted 2 gm, use 2 gm intravenously every day shift for infection for 7 days, start date 8/19/2023 and end date 08/26/2023. An order for saline flush 10 ml pre/post Administration of IV Medications every day shift for 7 days, start date 8/19/2023 to 8/26/2023. An order to discontinue the IV line to right upper arm, ABT completed. The date ordered and completed was on 08/29/2023 at 12:30 PM, after the facility was notified by the surveyor on 08/29/2023 at 10:40 AM. Record review of Resident #1's Active Orders as of 8/29/2023 revealed no order for dressing change and no order for saline flushes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 4 of 14 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 08/30/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's MAR/TAR/LNR for August 2023 revealed there was no scheduled dressing change for the PICC line. Further review revealed there was no scheduled saline flushes after 08/25/2023. Observations and interview on 08/29/2023 at 10:36 AM revealed Resident #1 lying in bed. The resident was well dressed, in no immediate distress with an IV site to his right upper arm. The transparent IV dressing was intact. The dressing was dated 08/17. There was a Biopatch Protective Disc over the IV insertion site. There was a small pocket of air and a small amount of dark red blood at the bottom edge of the Biopatch and blood alongside a small section of the tubing. Resident #1 stated the IV was placed while in hospital on the same date written on the dressing. Resident #1 stated the IV had not been used in maybe 3 days and he did not know when it was flushed last, and he did not know why the cap was off of one of the lumens. He denied any pain. In an observation and interview on 08/29/2023 at 10:40AM, LVN A visually assessed Resident #1's PICC line and stated the date on the dressing was 08/17 and that it needed to be changed because it was supposed to be changed weekly, d/t risk of infection. LVN A stated there should be no blood at the insertion site but Resident #1 was mobile and active, so that was what could have caused it to bleed. In an interview on 08/29/2023 at 10:55 AM the DNS stated that IV dressings should be changed every 7 days in order to keep the IV site clean. In an interview on 08/30/2023 at 12:30 PM, LVN A/Clinical Support Nurse stated the Resident #1's next dressing change would have been 7 days from the start of the antibiotics. LVN A stated it should have been changed on 8/25/2023. LVN A stated she did not know about the facility policy to change the catheter dressing 48 hours from insertion and did not know why this was in the policy and procedure. LVN A stated she was the one who put the antibiotic order in after she noticed it had not been done. LVN A stated she did not expect Resident #1 needing a dressing change and technically the PICC should have been discontinued. LVN A stated if she was the nurse who gave the last dose, she would have followed up with the MD for further instructions. If the MD ordered to continue with the PICC she would then ask for flush orders and a dressing change order since, 7 days had passed. She stated it should be the ADNS and DNS to monitor for the follow up but sometimes things were just not caught. She stated the completion of Resident #1's IV antibiotics should have come up in the IDT meetings. She stated that the IP had already conducted nursing in-service and training on the importance of maintaining the IV. In an interview on 08/30/2023 at 1:05 PM, the ADNS stated she gave the IV antibiotic Ceftriaxone to Resident #1 on 08/23/2023. The ADNS stated the IV dressing would have been changed on the last day which was 8/25/2023. She stated the nurse should have contacted the provider to see if additional IV medications were needed and if the PICC line was to be used further, then she would place an order in for dressing changes. She stated that normally the orders would be double checked after the end of the antibiotic treatment. She stated this would have been discussed in clinical meetings in the AM and again in the afternoon end of day meeting. The ADNS stated she did not know why it got missed. In an interview on 08/30/2023 at 1:30 PM, LVN C stated she gave Resident #1 the last dose of IV Ceftriaxone on 08/25/2023. She stated she did not call the MD to notify that the resident had completed the IV antibiotics and she would have charted this if she did. LVN C stated on Sunday 8/27/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 5 of 14 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 08/30/2023 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 0694 Level of Harm - Minimal harm or potential for actual harm they were waiting for the doctor to call back. She stated the person responsible to get orders for the dressing change would be the nurse assigned to the resident and that it was a very busy at that time, so it got missed. LVN C stated normally they do have orders for dressing changes, usually it was a separate batch order and would depend on who put the order in. LVN C stated they did not receive any orders for dressing changes from the MD. Residents Affected - Few In an interview on 08/29/2023 at 4:30 PM, the DNS stated the dressing change order for Resident #1 should be in the MAR/TAR. She stated some orders were on a batch order system and IVs would normally be ordered this way. She stated the nurse who placed the order must have clicked off on some of the options because of the short duration of the antibiotic order. She stated clicking off on the options for dressing changes every 7 days should not have been done. Record review of a sample batch order (a page where orders were first entered into resident's electronic healthcare records), given to surveyor by the DNS on 08/30/2023 revealed the available check boxes for PICC line-monitor for infection, PICC-no venipuncture, PICC dressing change (biopatch present), PICC-dressing change (no biopatch present), PICC-flush with normal saline before and after medication administration. Record review of LVN C's Competency Assessment checklist, Guidelines for Preventing Intravenous Catheter-Related Infections signed by LVN C and the trainer/ DCE on 08/21/2023 revealed LVN C demonstrated and met all the goals. Record review of the DCE's Competency Assessment checklist, Guidelines for Preventing Intravenous Catheter-Related Infections signed by the DCE and the DNS on 06/24/2022 revealed DCE demonstrated and met all the goals. Record review of the facility's policy and procedure read in part: Competency Assessment, Guidelines for Preventing Intravenous Catheter-Related Infections, revised August 2014 read in part: A) Purpose-The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous catheters. B) General Guidelines, 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: c. - appropriate infection control measures to prevent IV catheter-related infections.Overview of CRI (catheter related infections) 1. Potential risk factors associated with central venous access device (CVAD) and infusion related infections include: .c. multi-lumen catheters .Catheter Site Dressing Regimens, 1. Change initial dressing after catheter placement within 24 hours .4. Change TSM (Transparent, semi permeable membrane) dressing on CVAD (Central Venous Access Device) every 5-7 days or PRN if damp, loosened or visibly soiled. This does not require a physician's order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 6 of 14 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 08/30/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff were able to demonstrate competency in the provision of skills and techniques necessary to care for one resident (Resident #2) reviewed for incontinent care in that: -CNA D failed to wipe Resident #2's perineal area using only a front to back motion. - CNA D failed to follow proper procedures by using gloves from her pocket when performing incontinent care. - CNA D failed to follow proper procedures by not changing gloves and hand sanitizing prior to touching clean items. These failures could place residents requiring incontinence care at risk for discomfort, skin breakdown, cross contaminations, and urinary tract infections. Findings included: Resident #2 Record review of Resident #2's Face Sheet dated 08/30/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include left arm fracture, right toe fracture, heart failure, chronic kidney disease state 4, diabetes and cancer of the colon. Record review of Resident #2's admission MDS dated [DATE] revealed intact cognition as indicated by a BIMS score of 13 out of 15, he required one person assist for bed mobility. He was always incontinent of bowel and bladder. He was not at risk for developing pressure ulcers/injures. Record review of Resident #2's care plan last reviewed on 08/11/2023 revealed Focus - Resident #2 had self-care deficit r/t incontinent of bowel & bladder. Goal - Resident #2 will maintain or improve his ability to participate with ADLs through the next review date. Interventions included - Toileting/incontinent care by one person assist. Focus - Resident #2 had fragile skin and at risk for skin injury, new or worsening skin condition. Goal - Resident #2 will have intact skin, free of redness, blisters, or discoloration by review date. Interventions included - apply treatment as ordered. Keep clean & dry and apply skin barrier cream as indicated. Handle fragile skin with caution & report to nurse if any skin concerns arise. Resident #2 was at risk for infection or recurrent/chronic infection r/t compromised medical condition. Goal - Resident #2 will not experience any complications or adverse reactions throughout the course of treatment through the next review date. Interventions included - Report changes in condition to MD. Resident #2 had incontinence r/t activity intolerance, history of UTI, impaired mobility, and physical limitations. Goal - Resident #2 will remain free from skin breakdown d/t incontinence and brief use through the review date. Interventions included ask and assist resident to toilet during waking hours as indicated. Check and change on rounds as needed. Incontinent care assistance every shift and as needed. During an observation of incontinent care for Resident #2 on 08/30/2023 at 9:30 AM, CNA D sanitized her hands prior to entering the resident's room and explained the procedure to Resident #2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 7 of 14 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 08/30/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #2 was positioned in bed for a brief change. CNA D put on gloves. The brief was noted to have a large amount of soft bowel movement. CNA D cleansed the tip of penis and down the shaft of the penis with disposable cleansing wipes from a package on the nightstand., CNA D cleansed the right groin and left groin with new cleansing wipes from the package. CNA D cleansed the front of the scrotum with a new cleansing wipe. Resident #2 rolled to his right side. CNA D rolled the soiled brief, removing it from under the resident and disposed into the trash bin. CNA D removed gloves placed it into the trash bin and took gloves from her pocket and put them on.u CNA D took some cleansing wipes from the package and wiped starting from the top of the gluteal cleft and moved downward towards and over the rectum. CNA D took more wipes from the package and repeated the same process from the top of gluteal cleft towards and over the rectum. CNA D took more wipes from the package and cleansed the perineum area starting from the direction of the rectum to the base of the scrotum. There was feces on the back of both thighs. CNA D cleansed the back of the thighs in an upward direction towards the gluteal fold using cleansing wipes from the package. CNA D removed her gloves, tossed them into the trash bin and took gloves from her pocket and put them on. The resident rolled onto his back. CNA D cleansed the groin area, around and beneath the scrotum. The resident had visible hemorrhoids. CNA D cleansed the area and the cleansing wipe had small spots of blood. The scrotum was pinkish red. The skin beneath the scrotum and towards the rectum were red. There were no open areas noted. CNA D placed and secured the clean brief beneath the resident. CNA D touched the resident's clothing and the bed linens while repositioning the bed covers on Resident #2. During an interview on 08/30/2023 at 9:55 AM, CNA D stated she had been working at the facility for 10 months. CNA stated incontinent care for the male was different than for a female. She stated she was thinking that she should wipe the bowel movement starting in direction of the head and then towards the feet. She stated she got confused. CNA D stated doing it the way she did could cause some cross contamination to the front of the resident. She stated the risk was infection that may enter through the penis. CNA stated she puts gloves in her pocket sometimes d/t situations when she needs gloves quickly. She stated her pocket was not clean and using the gloves from her pocket could cross contaminate bringing infection to the resident. CNA D stated she should not have touched the clean items with dirty gloves d/t risk of cross contamination. She stated the package of wipes were contaminated d/t the dirty gloves she used when touching them and she should not have done this. She stated she will ask the nurse about barrier cream to Resident #2's bottom. During an interview on 08/30/2023 at 11:25 AM, the DNS stated nursing staff should be using gloves from the glove box holder on the back of each resident's room door. The DNS stated nursing staff should not pocket gloves d/t infection control. She stated the clean gloves placed in pockets could get contaminated when we brush up against anything. The DNS stated she expected nursing staff to start incontinent care at the penis, move downward and always from clean area to dirty area. The DNS stated she expected nursing staff to clean from front to back. She stated doing it this way would get all contaminated body fluids away from the meatus of the penis. The DNS stated bringing contaminated body fluids back to clean area could cause infection such as UTIs. The DNS stated when cleaning the buttocks, it was not ok to start from the top and move to the bottom and cleaning should always be from clean to dirty. The DNS stated it was not ok to touch the package of cleaning wipes with dirty gloves d/t the package would be contaminated. The DNS stated the best practice was to remove as many wipes needed before beginning incontinent care. The DNS stated soiled gloves should be removed and hands should be sanitized before putting on new gloves d/t soiled gloves may have unseen holes where contaminates can get into and then onto our hands. The DNS stated dirty gloves should be removed, hands should be sanitized before putting on new gloves when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 8 of 14 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 08/30/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few touching clean briefs and bed linens to prevent cross contamination. The DNS stated going forward she would be conducting in services on incontinent care for nursing staff along with competency checks to ensure incontinent care was done properly and to ensure the nursing staff understand the rationale behind proper incontinent care. Record review of the Competency Assessment, Perineal Care check list dated 03/08/2023 for CNA D revealed she met the goals. The check list was signed by CNA D and the trainer: DCE. Record review of the facility policy for Competency Assessment: Perineal Care, revised 02/2018 read in part A) Purpose - The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition D) Steps in the Procedure .For a male resident: .b. wash perineal area starting with the urethra and working outward .f. Continue to wash the perineal area including the penis, scrotum and inner thighs .m. Wash the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks . Further review did not reveal in which direction the perineum was to be cleansed. Record review of the facility policy and procedure for Handwashing/Hand Hygiene, revised August 2015, read in part: Policy Statement - This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation - 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: h. Before moving from a contaminated body site to a clan body site during resident care .m. After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .Applying and Removing Gloves - 1. Perform hand hygiene before applying non-sterile gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 9 of 14 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 08/30/2023 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Resident #1, Resident #2) reviewed for infection control. Residents Affected - Few -The facility failed to ensure an end cap was in place on one lumen of the double lumen PICC line for Resident #1. - CNA D failed to follow proper procedures by using gloves from her pocket when performing incontinent care. - CNA D failed to follow proper procedures by not changing gloves and hand sanitizing prior to touching clean items. This failure could place residents at risk for infection, injury, and hospitalization. Findings included: Resident #1 Record review of Resident #1's Face Sheet dated 08/29/2023 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include cellulitis (skin infection) of the left lower limb, diabetic peripheral angiopathy (disease of the blood vessels as a result of unregulated diabetes), proteus mirabilis (microorganism causing infection), heart disease, local infection of the skin and peripheral vascular disease (a blood circulation disorder). Record review of Resident #1's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, he required extensive assistance with bed mobility and toilet use. He required limited assistance with transfers, dressing and personal hygiene. He was occasionally incontinent of bladder and always continent of bowel. He had infection of the foot and diabetic foot ulcers. Record review of Resident #1's Care Plan last reviewed on 08/23/2023 revealed Focus-at risk for skin injury-new or worsening skin condition. Actual skin issues: left lower leg Cellulitis, left leg ulcers, both lower leg Venous statis (congestion and slowing of circulation in veins). Goal-skin injury will resolve without associated complications through the review date. Focus- at risk for infection or recurrent/chronic infection r/t compromised medical condition. Goal-will be free from S/S of infection and any complications r/t infection through the review date. Interventions included-administer medications and/or antibiotics as per MD orders. Doxycycline until 8/26/2023 and Ceftriaxone 2 gm until 08/26/2023 for left leg cellulitis. Focus-risk for complications associated with intravenous therapy. Goal-will be free from complications associated with IV placement through the next review date. Interventions included-administer medications and/or flushes as ordered by MD. Change dressing to IV access site as ordered. Frequent monitor/check IV access site upon each care encounter, look for s/s of infection. Record review of Resident #1's undated Completed Physician Orders revealed an order to monitor right upper arm IV-Line for S/S of infection every shift for 7 days, start date 08/19/2203 and end date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 10 of 14 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 08/30/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/26/2023. An order for Ceftriaxone Sodium Solution Reconstituted 2 gm, use 2 gm intravenously every day shift for infection for 7 days, start date 8/19/2023 and end date 08/26/2023. Record review of Resident #1's hospital clinical records dated 08/17/2023, revealed Impression and plan: left leg wound possible underlying deep infection, wound culture Proteus. Will de-escalate antibiotics to Ceftriaxone and add Doxycycline. During an observation and interview on 08/29/2023 at 10:35 AM, Resident #1 was lying in bed. He had a double lumen PICC in the right upper arm. The dressing was dry and intact. No redness or swelling was noted. One catheter lumen did not have an end cap. The lumen of the catheter was open to air, open to touching the resident's clothing, the resident's skin, and the resident's beddings. The lumen was clamped. The second lumen had a needleless connector capping the end. Resident #1 stated the PICC line had not been used in maybe 3 days and he did not know why the cap was off the end of the lumen. He said the nurse told him that one of the lumens could not be used and that the nurse may have left the cap off that lumen and placed the cap on the second lumen. He did not know the name of the nurse. He denied any pain. During an observation and interview on 08/29/2023 at 10:40 AM, LVN A assessed Resident #1's PICC line and stated it was the nurse's responsibility to ensure the ends of the lumens had solid end caps, as they were the ones infusing the medications. LVN A stated without a cap the risk to the resident was infection because the catheter was inside the vein. During an interview on 08/29/2023 at 10:55 AM, the DNS stated there was always an infection control concern if the end cap was off of the PICC line lumens. The DNS stated she would need to check the facility policy and procedure for the care of the PICC line if the catheter was found without end caps. During an interview on 08/29/2023 at 11:30 AM, LVN B stated Resident #1 was assigned to him. LVN B stated he got to the floor at 6:00 AM when his shift started and that this was his first day working at this facility. LVN B stated he was from the Agency. LVN B stated when he arrived all the residents were still asleep. LVN B stated he had not yet assessed Resident #1 d/t an emergency with another resident. LVN B stated he had no idea why the cap would be off the PICC. LVN B stated the report from the night shift nurse was that Resident #1 had an IV and according to the computer, the resident was not due for any IV antibiotics. LVN B stated the risk of having the end of the catheter open to air without a cap would be infection for Resident #1. LVN B stated he would notify the Healthcare Provider about the catheter not having the protective end cap and ask for guidance. During an interview on 08/29/2023 at 12:00 PM, the DNS stated even if the lumen of the PICC could not be used, she expected there to be a solid cap on the end. The DNS stated the cap was off so she will contact the MD, not use the PICC and ask for further instructions. The DNS stated, going forward she will conduct in services for the nursing staff on the care of the resident with a PICC. During an interview on 08/30/2023 at 1:30 PM, LVN C stated on Sunday 08/27/2023 she made sure there were caps on both ends of the double lumen PICC line for Resident #1. Record review of LVN C's Competency Assessment checklist, Guidelines for Preventing Intravenous Catheter-Related Infections signed by LVN C and the DCE on 08/21/2023 revealed LVN C demonstrated and met all the goals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 11 of 14 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 08/30/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Record review of the DCE's Competency Assessment checklist, Guidelines for Preventing Intravenous Catheter-Related Infections signed by the DCE and the DNS on 06/24/2022 revealed DCE demonstrated and met all the goals. Resident #2 Residents Affected - Few Record review of Resident #2's Face Sheet dated 08/30/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include left arm fracture, right toe fracture, heart failure, chronic kidney disease state 4, diabetes and cancer of the colon. Record review of Resident #2's admission MDS dated [DATE] revealed intact cognition as indicated by a BIMS score of 13 out of 15, he required one person assist for bed mobility. He was always incontinent of bowel and bladder. He was not at risk for developing pressure ulcers/injures. Record review of Resident #2's care plan last reviewed on 08/11/2023 revealed Focus - Resident #2 had self-care deficit r/t incontinent of bowel & bladder. Goal - Resident #2 will maintain or improve his ability to participate with ADLs through the next review date. Interventions included - Toileting/incontinent care by one person assist. Focus - Resident #2 had fragile skin and at risk for skin injury, new or worsening skin condition. Goal - Resident #2 will have intact skin, free of redness, blisters, or discoloration by review date. Interventions included - apply treatment as ordered. Keep clean & dry and apply skin barrier cream as indicated. Handle fragile skin with caution & report to nurse if any skin concerns arise. Resident #2 was at risk for infection or recurrent/chronic infection r/t compromised medical condition. Goal - Resident #2 will not experience any complications or adverse reactions throughout the course of treatment through the next review date. Interventions included - Report changes in condition to MD. Resident #2 had incontinence r/t activity intolerance, history of UTI, impaired mobility, and physical limitations. Goal - Resident #2 will remain free from skin breakdown d/t incontinence and brief use through the review date. Interventions included ask and assist resident to toilet during waking hours as indicated. Check and change on rounds as needed. Incontinent care assistance every shift and as needed. During an observation of incontinent care for Resident #2 on 08/30/2023 at 9:30 AM, CNA D sanitized her hands prior to entering the resident's room and explained the procedure to Resident #2. Resident #2 was positioned in bed for a brief change. CNA D put on gloves. The brief was noted to have a large amount of soft bowel movement. CNA D cleansed the tip of penis and down the shaft of the penis with disposable cleansing wipes from a package on the nightstand., CNA D cleansed the right groin and left groin with new cleansing wipes from the package. CNA D cleansed the front of the scrotum with a new cleansing wipe. Resident #2 rolled to his right side. CNA D rolled the soiled brief, removing it from under the resident and disposed into the trash bin. CNA D removed gloves placed it into the trash bin and took gloves from her pocket and put them on.u CNA D took some cleansing wipes from the package and wiped starting from the top of the gluteal cleft and moved downward towards and over the rectum. CNA D took more wipes from the package and repeated the same process from the top of gluteal cleft towards and over the rectum. CNA D took more wipes from the package and cleansed the perineum area starting from the direction of the rectum to the base of the scrotum. There was feces on the back of both thighs. CNA D cleansed the back of the thighs in an upward direction towards the gluteal fold using cleansing wipes from the package. CNA D removed her gloves, tossed them into the trash bin and took gloves from her pocket and put them on. The resident rolled onto his back. CNA D cleansed the groin area, around and beneath the scrotum. The resident had visible hemorrhoids. CNA D cleansed the area and the cleansing wipe had small spots of blood. The scrotum was pinkish red. The skin beneath the scrotum and towards the rectum were red. There were no open areas noted. CNA D placed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 12 of 14 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 08/30/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and secured the clean brief beneath the resident. CNA D touched the resident's clothing and the bed linens while repositioning the bed covers on Resident #2. During an interview on 08/30/2023 at 9:55 AM, CNA D stated she had been working at the facility for 10 months. CNA stated incontinent care for the male was different than for a female. She stated she was thinking that she should wipe the bowel movement starting in direction of the head and then towards the feet. She stated she got confused. CNA D stated doing it the way she did could cause some cross contamination to the front of the resident. She stated the risk was infection that may enter through the penis. CNA stated she puts gloves in her pocket sometimes d/t situations when she needs gloves quickly. She stated her pocket was not clean and using the gloves from her pocket could cross contaminate bringing infection to the resident. CNA D stated she should not have touched the clean items with dirty gloves d/t risk of cross contamination. She stated the package of wipes were contaminated d/t the dirty gloves she used when touching them and she should not have done this. She stated she will ask the nurse about barrier cream to Resident #2's bottom. During an interview on 08/30/2023 at 11:25 AM, the DNS stated nursing staff should be using gloves from the glove box holder on the back of each resident's room door. The DNS stated nursing staff should not pocket gloves d/t infection control. She stated the clean gloves placed in pockets could get contaminated when we brush up against anything. The DNS stated she expected nursing staff to start incontinent care at the penis, move downward and always from clean area to dirty area. The DNS stated she expected nursing staff to clean from front to back. She stated doing it this way would get all contaminated body fluids away from the meatus of the penis. The DNS stated bringing contaminated body fluids back to clean area could cause infection such as UTIs. The DNS stated when cleaning the buttocks, it was not ok to start from the top and move to the bottom and cleaning should always be from clean to dirty. The DNS stated it was not ok to touch the package of cleaning wipes with dirty gloves d/t the package would be contaminated. The DNS stated the best practice was to remove as many wipes needed before beginning incontinent care. The DNS stated soiled gloves should be removed and hands should be sanitized before putting on new gloves d/t soiled gloves may have unseen holes where contaminates can get into and then onto our hands. The DNS stated dirty gloves should be removed, hands should be sanitized before putting on new gloves when touching clean briefs and bed linens to prevent cross contamination. The DNS stated going forward she would be conducting in services on incontinent care for nursing staff along with competency checks to ensure incontinent care was done properly and to ensure the nursing staff understand the rationale behind proper incontinent care. Record review of the Competency Assessment, Perineal Care check list dated 03/08/2023 for CNA D revealed she met the goals. The check list was signed by CNA D and the trainer: DCE. Record review of the facility policy for Competency Assessment: Perineal Care, revised 02/2018 read in part A) Purpose - The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition D) Steps in the Procedure .For a male resident: .b. wash perineal area starting with the urethra and working outward .f. Continue to wash the perineal area including the penis, scrotum and inner thighs .m. Wash the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks . Further review did not reveal in which direction the perineum was to be cleansed. Record review of the facility policy and procedure for Handwashing/Hand Hygiene, revised August 2015, read in part: Policy Statement - This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation - 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 13 of 14 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 08/30/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few healthcare-associated infections 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: h. Before moving from a contaminated body site to a clan body site during resident care .m. After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .Applying and Removing Gloves - 1. Perform hand hygiene before applying non-sterile gloves . Record review of the facility's policy and procedure for read in part: Competency Assessment, Guidelines for Preventing Intravenous Catheter-Related Infections, revised August 2014 read in part: A) Purpose-The purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous catheters. B) General Guidelines, 1. Facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy, including: c. - appropriate infection control measures to prevent IV catheter-related infections.Overview of CRI (catheter related infections) 1. Potential risk factors associated with central venous access device (CVAD) and infusion related infections include: .c. multi-lumen catheters .Nursing Practice Guidelines to Prevent Catheter-Related Infections, Surveillance .6. Any time that a dressing is not intact or end caps are missing, the catheter has potential for contamination .Multi-Lumen Catheters .3. If catheter is found to have clotted blood in lumens or if catheter is found without needleless connection devices (end caps) or sterile dressing, the catheter should be considered contaminated, and replacement is recommended . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 14 of 14