Health inspection·March 28, 2024

F 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few summary would be a documentation error and did not know why discharge on Resident # 57 and Resident #112 was not completed. RN assessment coordinator A and RN assessment coordinator B report that they are included in daily facility meeting which includes discharge planning. During an interview on 03/28/2024 at 3:45 p.m., the RN Regional Clinical Nurse stated she had in-serviced the staff regarding RAI guidelines. Record review of the CMS version 3.0 Manual last revised October 2023 revealed in part . Nursing homes are required to submit Omnibus Budget Reconciliation Act required Minimum Data set records for all residents in Medicare or Medicaid certified beds regardless of payment source . must be no later than 14 days from the determination of significant change . PPS must occur within 7 days . Record review of facilities policy titled; CMS's RAI Version 3.0 Manual Ch 2: Assessments for the RAI., page 2-11., dated October 2023 read in part . Discharge assessments refers to an assessment required on resident discharge from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 2 of 4 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 03/28/2024 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 resident rooms was adequately equipped at the resident's bedside to call for staff assistance through the communication system for 1 of 3 sampled residents (Resident #6) reviewed for call light function, in that: Residents Affected - Few -The facility failed to ensure Resident #6 bedside call light was functioning. Findings included: Record review of Resident #6's face sheet, dated 03/28/2024, revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with hemiplegia (one-sided paralysis of the body) , anxiety disorder, dementia, and cerebral infarction (disrupted blood flow to the brain). Record review of Resident #6's MDS, dated [DATE], revealed the resident needed supervision to touching assistance for toileting showering, dressing and personal hygiene. Record review of Resident #6's care plan, not dated, reflected a focus noting resident had a self-care deficit related to diagnosis including weakness, debility, incontinence of bowel and bladder and poor physical endurance. The resident was noted need to need assistance by one staff for transfers. The care plan also revealed the resident was at risk for falls and the intervention to prevent injuries from falls was to anticipate needs and ensure call light was in reach for use. Observations of Resident #6 on 03/26/2024 at 10:37AM, revealed the resident was lying in bed with complaints of pain around her neck and chest area. Surveyor asked for the resident to press her call light and observed that it was not turning on when pressed. Resident was observed with a sign in her room that read, Please Call Don't Fall. The resident could not report how long her call light was not working. In an interview with the Director of Clinical Education on 03/26/2024 at 10:45AM, she acknowledged Resident #6's call light at that time was not working and stated she was not aware of the malfunction. She stated she would have to report the issue to the Maintenance Director. She stated it was important to ensure call lights were working in case a resident was experiencing an emergency and to ensure the residents' safety. In an interview with the Maintenance Director on 03/28/2024 at 2:55PM, he stated he was told about the concern today and he replaced the broken call light right away. He stated call lights needed to work in case of an emergency in case they fall or need help in the restroom and having a non-functioning call light places residents at risk for delayed care. He stated he performed monthly audits on call lights, and usually had to replace some call lights due to wear and tear on the chords or change lightbulbs that were dead. In an interview with the Administrator on 03/28/24 at 3:55PM, she revealed they did not have a facility policy on call light function. She stated call lights were supposed to be functioning to allow residents to call for assistance and ensure no delays in care. In an interview with 03/28/24 at 4:00PM, RN A stated Resident #6 was cognitively impaired but her impairment comes and goes. She said at times she was cognitive enough to use a call light or let (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 3 of 4 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 03/28/2024 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 0919 Level of Harm - Minimal harm or potential for actual harm someone know when she needed assistance. She stated she was not sure if a call light was important for Resident #6 because her room was located close to where she worked most of time and she could audibly hear the resident talk out loud when asking for help. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676350 If continuation sheet Page 4 of 4