Health inspection·December 30, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that housekeeping and maintenance services maintained a sanitary, orderly, and comfortable interior for 1 (Resident #135) of 7 residents reviewed for environment. -Resident #135's restroom had a sewage odor causing the resident not to want to use the restroom to shower. This failure placed her at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues. Findings include: Resident #135 Record review of Resident #135's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included hypertension (a condition in which the force of the blood against the artery walls is too high), symptoms and signs involving musculoskeletal system (the performance of the locomotor system, comprising intact muscles, bones, joints, and adjacent connectives tissues), need for assistance with personal care, bone density and structure, atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). Record review of Resident #135's care plan dated 11/04/2022 read in part . prefers to be showered 2-3 times weekly (date initiated on 12/24/2022). Resident #135 has a self-care deficit r/t weakness (date initiated on 12/24/2022). Resident #135 care plan also revealed she may be at risk for self-care deficit, falls, skin concerns, pain, infection and nutritional/hydration concerns and emotional distress. Dressing and grooming by 1 person assistance (date initiated on 12/24/2022). Resident #135 has a self-care deficit r/t weakness, and she may be at risk for self-care deficit . Observation and interview on 12/29/22 at 2:30 p.m., with Resident #135, revealed her sitting in a wheelchair with a pillowcase across her lap. Resident #135's room had food particles, pieces of white paper, and dark particles on the floor. The particles were on both sides of Resident #135's bed. Resident #135 restroom had a sewage odor. Resident #135 said the sewage odor was the reason she did not want to take a shower. Resident #135 said she had the pillowcase across her lap because she was ashamed and did not want visitors to see her wet. Resident #135 also said she had her call light on, but one of the staff members turned off the light and did not return. Resident #135 removed the pillowcase from her lap and her shorts were saturated with urine from her peri area and down below her Page 1 of 29 676356 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few knees. Resident #135 said the morning aide changed her around 10:00 a.m. and transferred her to her wheelchair, but never change her. Resident #135 said she had to wait for the second shift nursing staff to change her and it was humiliating. In an Interview on 12/30/2022 at 9:55 a.m., with the maintenance director, revealed he is usually in and out of all the resident's rooms, at least 5 to 10 times a day. He said there had recently been a sewage problem that he discovered two days ago. He said a CNA reported to him that there was a bad smell inside Resident #135's room. He said the floor drain dried up due to Resident #135 not running the water, and it caused a smell. The maintenance director said he did not check in every resident's room regarding the smell. He said room [ROOM NUMBER], where Resident #135 resides, was the only room with the smell. He also said he mixed water with a disinfected, and it took care of the smell. He said he has not been inside the room today. In an Interview on 12/30/2022 at 10:10 a.m. with the account manager for housekeeping, said she trains individuals to become managers in different locations. She said she does not handle biohazard materials, only CNA's handles that. She said housekeeping should not come out of the rooms with gloves on their hands because it can cause cross contamination. She also said she does monthly in-service on infection control. In an interview on 12/30/2022 at 5:06 p.m., with the Admin, he revealed that if a drainage is stopped up, staff will call maintenance and allow maintenance to access the problem. He said if maintenance cannot access the problem, a plumber will be called to the facility to see about the problem. He said he was aware that Resident #135 had a drainage issue. He said he found out about it on yesterday. He said maintenance determined that if the shower isn't being utilized, and the drained isn't being flushed with water, the drain will dry up and the residue inside will cause an odor. He also said bleach with water or a disinfected product with water will take care of the job. [NAME] said if Resident #135 isn't being bathed and not receiving a bed bath then that's a problem. He said the problem regarding to the odor has been taken care of. He said he does not know how long the odor had been there, but he goes to the resident's rooms often to check and see if they are having any issues. Record review of the facility's policy titled Departmental (Maintenance) Plumbing, HVAC and Related Systems revised on 06/11 read in part . The purpose of this procedure is to guide the sanitary handling of the plumbing, heating, ventilation, air conditioning, and related systems within the facility. The plumbing system should be manipulated with caution. Use barriers, including isolation barriers, when indicated to prevent exposure to blood, bodily fluids, excretions, and secretions. Use isolation barriers as necessary. Disinfect tools that are contaminated with blood or bodily fluids, excretions, or secretions. This includes used plumbing snakes, wet-vacs, and similar soiled items. If there is an overflow due to an occluded pipe, snake pipes or drains cautiously. If safety permits, wear heavy-duty gloves. Disinfect or discard gloves at the end of procedure. Wear appropriate safety eyewear. Flush drains in the janitor's closet, laundry, showers, tubs, kitchen, etc., at least quarterly. Maintenance personnel should wash their hands before and after leaving nursing areas, and especially following exposure to plumbing skills . . 676356 Page 2 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #135) of 7 residents reviewed for ADLs. Residents Affected - Few The facility failed to provide routine showers and timely incontinent care to Resident #135. These failures placed residents at risk of poor personal hygiene, skin problems, infection, and a diminished quality of life. Findings included: Record review of Resident #135's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses were hypertension (a condition in which the force of the blood against the artery walls is too high), symptoms and signs involving musculoskeletal system (the performance of the locomotor system, comprising intact muscles, bones, joints, and adjacent connectives tissues), need for assistance with personal care, bone density and structure, atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). Record review of Resident #135's care plan dated 12/24/22 read in part . prefers to be showered 2-3 times weekly (date initiated on 12/24/22). Resident #135 has a self-care deficit r/t weakness (date initiated on 12/24/22). Resident #135 care plan also revealed she may be at risk for self-care deficit, falls, skin concerns, pain, infection and nutritional/hydration concerns and emotional distress. Dressing and grooming by 1 person assistance (date initiated on 12/24/22). Resident #135 has a self-care deficit r/t weakness, and she may be at risk for self-care deficit . In an observation and interview on 12/27/22 at 10:30 a.m., with Resident #135, revealed her lying flat on her back, in bed, she was wearing a face mask. Resident #135 said she had been lying in her feces since 6:00 a.m. She said she pressed the call light button twice, and since that time she has been waiting fifteen minutes for assistance. She said staff told her they would return to her room and give her a bath. She said she wanted to be clean before her family came to visit her. Resident #135 said one of the CNA's did not put her in the bed last night at the time she requested. She said they told her she was too top heavy, and another staff member would need to help assist with transferring her to the bed. In an observation and interview on 12/29/22 at 2:30 p.m., revealed Resident #135 was sitting in a wheelchair in her room, she had a pillowcase draped across her lap. Resident #135 stated she had the pillowcase across her lap because her pants were soaked with urine, and she would feel ashamed if her visitors saw her clothes wet. Resident # 135 stated she was transferred to the wheelchair around 10:00 a.m. and had not been changed since then. Resident # 135 stated she turned her call light on, and staff came and turned it off and stated she would be back, and she did not come back. Resident #135 removed the pillowcase, for the surveyor to see her soiled clothes, her shorts was saturated with urine from her peri area to the end of her shorts which was below her knee. Resident #135 stated once the aide put her in the chair around 10:00 a.m., she would be changed again when the afternoon shift came and changed her. In an observation and interview on 12/29/22 at 3:24 p.m., revealed staff coordinator and CNA AA 676356 Page 3 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few providing incontinent care for Resident #135. Resident #135's feet were ashy, dry, scaly, and flaking on the bed. CNA AA said she observed Resident #135 feet was dry and scaly and the skin was falling off on the bed, she said Resident #135's feet needed to be greased. When Resident #135 shorts were removed, the buttocks' area and the entire back to the end of the shorts were wet. Both staff members acknowledged the shorts were wet from front to back. When Resident #135 incontinent brief was unfastened, it revealed it was saturated with urine and had bowel movement. The stuffing in the brief was broken apart and the wet indicator line was completely smashed. CNA AA said the brief was very wet and the inside of the shorts were coming apart. During incontinent care, the staff coordinator did not separate the labia or buttocks and wipe in that area. She turned Resident #135 to the left and wiped the right buttocks but did not wipe the left buttock. She was about to apply the clean incontinent brief, but the surveyor intervened. The staff coordinator separated the labia and buttocks and wiped each area three times. She also wiped bowel movement as well. In an interview on 12/30/22 at 9:05 a.m., the DON stated the aides try to do rounds every two hours for incontinent care, and sometimes they make rounds more often. The DON stated if Resident #135 was left on a saturated incontinent brief, Resident # 135 could have skin breakdown or skin rashes. She said the nurse, ADON, and director of clinical education monitored the aides. In an interview on 12/30/22 at 9:32 a.m. with the DON, she said she did not know that Resident #135 had not been showered since she arrived at the facility. She said she did not know Resident #135's skin was dry which showed crust and white flakes. She said if the aides do not apply lotion on residents, the skin starts to itch, and the dry skin can flake off. In an Interview on 12/30/22 at 5:00 p.m., with the Corporate Nurse, revealed that she updated the care plan on the spot, regarding Resident #135, adding, Resident #135 prefers to do her own bathing (date initiated 12/30/2022). Resident #135 denied during interview with surveyor that she prefers to do her own bathing. In an Interview on 12/30/22 at 5:35 p.m., with Resident #135, revealed staff has been running around trying to clean stuff up. She said she doesn't know why she hasn't taken a bath since she entered the facility. She said staff only wipes her bottom if they change her diaper. She said she washes the top part of her body because no one comes to assist her with a shower. She said the bathroom has a bad odor. She said she doesn't want to take a bath in a dirty shower. She also said her daughter noticed the smell and reported it to a staff member. Record review of the facility's policy titled Quality of Life dated February 2017 read in part . The community will promote care for residents in a manner and an environment maintenance or enhancement of each resident's quality of life and in an environment that maintains or enhances each resident's dignity and respect in full recognition his individuality. A resident has the right to reside and receive services in the community with reasonable accommodation of individual needs and preferences, except when the health and safety of the individual or other residents would be encouraged and received notice that the resident's room or roommate in the community is changed . 676356 Page 4 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Residents #40 and #75) of 7 residents reviewed for quality of care. Residents Affected - Few The facility failed to prevent Residents #40 and #75 from developing MASD (Moisture Associated Skin Damage) causing them pain and emotional distress. These failures placed residents at risk of a diminished quality of care which lead to residents having severe pressure ulcers and severe moisure associated skin damage. Findings included: Resident #40 Record review of resident #40's face sheet revealed a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Her diagnosis was morbid, severe obesity (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), urinary tract infection, and retention of urine (a condition in which urine cannot empty from the bladder). Record review of Resident #40's Comprehensive MDS dated [DATE] revealed Resident #40 had a BIMs score of 04 indicating the resident was severely cognitively impaired. The Resident required one person assist with toileting. The MDS noted the resident was incontinent of bowl and had a Foley Catheter. The MDS Preferences for Customary Routine and Activities section noted it was very important to resident #40 to choose what clothes to wear and to choose between a tub bath, shower, bed bath, or sponge bath. Record review of Resident #40's Care Plan revised on 11/04/22 read in part . Resident #40 will remain free from catheter related trauma. Foley Catheter with perineal wipes and or soap and water. Q shift and PRN and activate task on POC every shift for pain. Bed mobility X1 person assistance as needed only. Hygiene 1 require 1 staff assistance for hygiene ADL's. Dressing and grooming X1 person assistance . Record review of Resident #40's skin assessment dated [DATE] read in part . Resident #40 has poor elasticity, normal temperature, dry skin, and very moist skin. Resident #40 is very limited to change or control body position. Resident #40 requires moderate to maximum assistance in moving, and she has MASD (moisture associated skin damage). Skin and wound evaluation: area 38.3 cm2, length 11.8 cm, width 6.7 cm, depth NA, undermining NA, turning NA . Observation and interview on 12/27/2022 at 11:05 a.m. with Resident #40, revealed her crying in her wheelchair while engaged in therapy. She said staff does not assist her in a timely manner. She said she had to wait 90 minutes for staff to respond to the call light. She said her bottom had changed from sitting in her feces and urine for too long. She said her bottom burned. She said the new administrator was doing what he could to change things at the facility. 676356 Page 5 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0684 Level of Harm - Actual harm Observation and interview on 12/29/2022 at 10:00 a.m., with Resident #40, revealed her engaged in therapy. She said last night around 7:00 p.m., she pushed the call light button for assistance with care but fell asleep around 11:00 p.m. because no one came to assist her. She said she woke up wet the next morning. Resident #40 was not wet during interview and observation. Residents Affected - Few In an interview on 12/30/2022 at 9:30 a.m. with DON, she said if residents had too much water or urine against their skin, then the skin would break down. She said she was not sure if Resident #40 and Resident #75 had seen the wound care doctor for the MASD. She said she had not seen the residents' skin areas recently. She said if residents were left wet for an extended period; they could develop MASD (moisture-associated skin damage). In an interview on 12/30/2022 at 10:50 a.m. with (MP), she said she does not see residents that has moisture-associated skin damage, (which is caused by prolonged exposure to various sources for moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents). She said leaking catheters, resident sweat, not being repositioned, and residents soiled in adult briefs with stool and urine can break down the skin in a matter of minutes. Observation and interview on 12/30/22 at 2:40 p.m., revealed the treatment nurse assisted by CNA T were providing wound care to Resident #40. CNA T placed the foley bag on the bed before the resident was turned to her side and it was left on the bed throughout her wound care. Resident #40 had a caked white substance on her sacrum, buttocks, and groin area, up to about one fourth of her upper thigh. The treatment nurse did not clean the caked area. The MASD had many tiny openings, red on the areas that did not have the caked-up barrier cream and were tender to the touch. The treatment nurse applied the barrier cream on top of the uncleaned caked area. The Foley bag was left on the bed for fourteen minutes. Resident #40 said the MASD was hurting badly. The Treatment nurse told Resident #40 that the cream she applied would stop the pain. The Treatment nurse measurements were: buttocks: 24 x 23 cm, inner left thigh to the groin measured 6 cm x 10 cm, and the right inner thigh measured the same. In an interview on 12/30/22 at 3:11 p.m. with CNA T, she said she placed the Foley bag on the bed because she did not want the bag to hit the floor. She said the urine flowed back into the bladder. She said she did not know what could happen to the residents when urine flowed back into the bladder. CNA T said she had been in-serviced on how to take care of a residents with Foley's. She said she no had told her not to place a Foley bag on the bed during in-service. She said she thought that was how she was supposed to clean the Foley from the vagina down. In an interview on 12/30/22 at 3:28 p.m., the Treatment nurse stated Resident #40's wound care order did not state to clean the area before applying barrier cream. The Treatment nurse stated she did not clarify the order with Resident #40's doctor. The Treatment nurse stated Resident #40 was cleaned when she was provided incontinent care before she came and applied the cream. The Treatment nurse stated to trust her because the arrier cream was not designed to be wiped off completely, and the incontinent wipes would not be able to cleanse the cream. The Treatment nurse stated the area would be washed clean during the shower because you have to use a towel and soapy water to clean the area for the barrier to come out. When she was asked why she did not use a towel and soapy water to wash the MASD area, she did not respond. The Treatment nurse and the surveyor read the instructions on the barrier cream, which read, wipe the area clean and allow to dry, then apply the cream. The Treatment nurse stated she should have washed the area before she applied the barrier cream. The Treatment nurse stated Resident #40 was admitted with Foley and was unsure if the Foley had leaked. The Treatment nurse stated Resident # 40 was on antibiotics, and she had diabetes, which could make her urine 676356 Page 6 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0684 more concentrated, and Resident # 40 does sweat a lot, and which could cause a break in her skin. The Treatment nurse stated the staff should have changed Resident #40 more often to help prevent the MASD. Level of Harm - Actual harm Residents Affected - Few Interview on 12/30/2022 at 3:57 p.m., the DON said she did not know how long Resident #40 developed MASD, but it has been there for a while. She said if the staff changed Resident #40 often and kept her dry, this may not have happened. She said she was not sure if the resident Foley had leaked because she had Foley upon admission. Interview and record review on 12/30/22 at 4:23 p.m., Resident #40's admission skin assessment with the DON, treatment nurse , and Corporate Nurse revealed Resident #40 was readmitted to the facility on [DATE] and there was no skin assessment until 11/07/22. The DON, treatment nurse, and Corporate Nurse stated the initial date of MASD was 11/11/22, and the previous wound care nurse put it in. In an Interview on 12/30/2022 at 4:54 p.m. with LVN K, revealed that the primary doctor gave her the standing order to apply Zinc for MASD. LVN K said MASD started because the Foley was leaking. She said she did not know how long the Foley had been leaking. She repeated she did not know how long it was leaking and it caused the MASD. She said if the aides providing care timely and stopped the leakage, the resident may not have had a skin issue. In an interview on 12/30/2022 at 5:02 p.m. with Corporate Nurse, she said if Resident #40 sweats and the Foley was leaking, then staff should continue to assess Resident #40 and change her. She said she did not have timely intervention in place but to change the resident. In an Interview with the MD on 12/30/2022 at 5:05 p.m., he said it has been long time since he gave the order for MASD and he cannot recall, he said during the Foley leakage he said, Resident #40 is wet all they can do is provide peri care and keep her dry to prevent the skin break down and the facility staff are doing that already. He said Resident #40 had so much to complain about whenever he sees her. He said whatever the order read and if the facility staff said he gave the order that means he did. Resident #75 Record review of Resident #75's face sheet revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, hypertension (persistently raised blood pressure), atrial fibrillation (irregular heartbeat, heart beats faster than normal) and need for assistance with personal care. Record review of Resident #75's admission MDS assessment, dated 10/31/22, revealed a BIMS of 11 indicating moderately impaired cognition. Resident #75 needs extensive assistance with ADL care with one staff assistance and the resident was incontinent of bowel and bladder. Record review of Resident #75's care plan dated 11/03/22 revealed Resident #75 had ADL (activity of daily living) self-care performance deficit related to pain in left hip. Intervention: resident needed extensive assist with two-person assistance with toilet use. It also revealed pressure ulcer or potential for pressure ulcer related to incontinent of bowel and bladder. MASD (moisture related skin damage) stared on 11/08/22, skin fragile and at risk for injury - new or worsening skin condition. Interventions: apply treatment s ordered, keep skin clean and dry and apply skin barrier cream as indicated. 676356 Page 7 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0684 Record review of Resident #75's Braden scale dated:10/30/22, 11/06/22, 11/22/22, 11/26/22 read in part . Resident #75 score was 14 which indicated moderate risk for pressure sore risk . Level of Harm - Actual harm Residents Affected - Few Record review of Resident #75's skin assessments dated, 10/24/22, 10/31/22, 11/16/22, 11/21/22, 12/05/22, 12/14/22 and 12/19/22 indicated the resident did not have new wounds. Record review of Resident #75's order summary report dated December 2022 revealed there was no order for MASD. Observation and interview on 12/30/22 at 2:36 p.m., revealed Resident #75 wound was treated by the treatment nurse . She said Resident #75's wound was almost gone. When she unfastened the incontinent brief, she said it looked worse than it did on yesterday, and now it was on his groin area, penis, and scrotum. She said we must go to another resident and come back to him later. She said he was bleeding from some of the open areas and there was fresh blood on Resident #75 incontinent brief. She said as of yesterday he was at the tail end of MASD. Observation on 12/30/22 at 2:58 p.m., revealed the treatment nurse was given to Resident #75 and treated by treatment nurse and was assisted by CNA T. CNA T grabbed gloves from her uniform pocket and donned it. She entered Resident #75's room and assisted the resident to his side. There was still fresh blood on the brief and some of the multiple open areas was still bleeding. The treatment nurse did not clean MASD areas before she applied the barrier cream. Resident #75 stated the MASD area was hurting, and the treatment nurse said the barrier cream would stop it from hurting. Observation on 12/30/2022 at 3:45 p.m., the treatment nurse said the area on Resident #75 was better on yesterday, but it was worse on today. She said that Resident #75 was using the urinal, but he was still incontinent, and they must monitor and make sure the aides are changing him in a timely manner and is kept dry. Resident #75's MASD on the buttocks measured 23 cm x 12 cm. The right thigh was 9 cm x 11.5 cm and the left thigh 9 cm x 10 cm. The groin area was red and MASD. Interview on 12/30/22 at 4:03 p.m., the DON stated Resident #75 used a urinal and the aides emptied the urinal and Resident #75 was incontinent he had to be checked and changed often, or Resident #75 skin could be damaged more. Interview on 12/30/2022 at 4:46 p.m., with Resident #75, said he was admitted on [DATE]. He said he uses a diaper and a urinal to release himself. He said there are times he has waited a long time for staff to assist him with care. He said he has waited 3 to 4 hours for assistance and that has happened twice since he has been at the facility. Resident #75 said he has a sore near his groin area that has been there for 10 days or two weeks. He said staff is treating his sore by changing his diaper and applying some type of cream. Record review of the facility's policy titled Quality of Care revised on (no revision date) read in part . Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. Based on the comprehensive assessment of a resident, the community will ensure that resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The community will ensure a resident who enters the community without limited range of motion does not experience reduction in range of motion unless the 676356 Page 8 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0684 Level of Harm - Actual harm Residents Affected - Few resident's clinical condition demonstrates that reduction in range of motion is unavoidable. The community will ensure a resident who is continent of bladder and bowl on admission receives services and assistance to maintain continence unless his or her clinical condition is or become such that continence is not possible to maintain. For a resident with urinary incontinence, based on the resident's comprehensive assessment, the community will ensure that, a resident who enters the community without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates catheterization was necessary . . 676356 Page 9 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 residents who were incontinent received appropriate treatment and services to prevent urinary tract infections for 2 of 4 residents (Resident #30 and Resident #135) reviewed for catheter and incontinent care in that: The facility failed to ensure CNA T and the treatment nurse placed Resident # 30's Foley bag below the bladder during wound care. The facility failed to ensure WFM YY followed proper infection control procedures, and completely cleaned Resident #135, during incontinent care. These failures could affect residents, who were incontinent or had a catheter, and placed them at risk for urinary tract infection, discomfort, skin breakdown and decreased quality of life. Findings include: Resident #40 Record review of Resident #40's face sheet revealed a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Resident #40 diagnoses included morbid, severe obesity (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), urinary tract infection, and retention of urine (a condition in which urine cannot empty from the bladder). Record review of Resident #40's Comprehensive MDS dated [DATE] revealed Resident #40 had a BIMs score of 04 indicating the resident was severely cognitively impaired. Resident # 40 required one person assist with toileting and incontinent of bowel and had a Foley Catheter. The MDS Preferences for Customary Routine and Activities section noted it was very important to Resident #40 to choose what clothes to wear and to choose between a tub bath, shower, bed bath, or sponge bath. Record review of Resident #40's Care Plan revised on 11/04/22 read in part . Resident #40 will remain free from catheter related trauma. Foley Catheter with perineal wipes and or soap and water. Q shift and PRN and activate task on POC every shift for pain. Bed mobility X1 person assistance as needed only. Hygiene 1 require 1 staff assistance for hygiene ADL's. Dressing and grooming X1 person assistance . Observation and interview on 12/30/22 beginning at 2:40 p.m., it revealed Resident # 40 was provided wound care by treatment nurse and assisted by CNA T. CNA T placed the Foley bag on the bed before Resident #40 was turned to her side and the foley bag was left on the bed throughout the care which was for 14 minutes. CNA T stated the urine flowed back to Resident #40's bladder. The treatment nurse stated the urine flowed back into Resident # 40 because the Foley bag was at the same level as the bladder and could cause infection. The treatment nurse stated she just noticed the bag was on the bed now. 676356 Page 10 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 12/30/22 beginning at 3:11 p.m., CNA T stated she placed the Foley bag on the bed because she did not want the bag to hit the floor. CNA T stated the urine flowed back into the bladder. CNA T stated she was unsure what could be a negative outcome for Resident # 40 when urine flowed back into the bladder. CNA T stated she had in-service on how to take care of a resident with Foley but was not told why not to place the Foley bag on the bed during in-service or how it would cause harm to the resident if it paced on the same leave as the bladder. CNA T stated she was though how to clean the Foley catheter from the vagina downward. Interview on 12/30/22 beginning at 3:20 p.m., the DON stated CNA T should not have placed the Foley bag on the same level with the bladder because the urine would follow back to Resident #40'S bladder. DON also stated it could cause a bad bacterial infection and in - service should include why a Foley should not be placed at the same level of the bladder and the rationale. Resident #135 Record review of Resident #135's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Resident #135's diagnoses was hypertension (a condition in which the force of the blood against the artery walls is too high), symptoms and signs involving musculoskeletal system (the performance of the locomotor system, comprising intact muscles, bones, joints, and adjacent connectives tissues), need for assistance with personal care, bone density and structure, atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). Record review of Resident #135's care plan dated 11/04/022 read in part . prefers to be showered 2-3 times weekly (date initiated on 12/24/2022). Resident #135 has a self-care deficit r/t weakness (date initiated on12/24/2022). Resident #135 care plan also revealed she may be at risk for self-care deficit, falls, skin concerns, pain, infection and nutritional/hydration concerns and emotional distress. Dressing and grooming X1 person assistance (date initiated on 12/24/2022). Resident #135 has a self-care deficit r/t weakness, and she may be at risk for self-care deficit . Record review of Resident #135's Comprehensive MDS dated [DATE] revealed Resident #135 was a new admission. There were no BIMS noted. Observation on 12/29/22 beginning at 3:24 p.m. revealed Resident # 135 was provided incontinent care by WFM YY and was assisted by CNA AA. WFM YY did not separate Resident # 135's labia or buttocks. Resident #135 was turned to the left, and she wiped the right buttock but did not wipe the left buttock. WFM YY was about to apply the clean incontinent brief when the surveyor intervened; when WFM YY separated the labia and buttocks and wiped each area three times, she wiped out bowel movement three times from the labia and the rectal area. WFM YY applied hand sanitizer twice during incontinent care; WFM YY robbed her hands a couple of times, then WFM YY waved her front and back. WFM YY stated she was trying to dry her hands quickly. Interview on 12/29/22 beginning at 4:00 p.m., WFM YY stated she applied hand sanitizer two times during Resident #135 incontinent care. She fanned her hands two separate times for her hands to dry quickly. WFM YY stated hands should be rubbed together until dry to kill the germs. WFM YY said she wiped out bowel movements from the labia and buttocks' when she separated the areas. WFM YY stated there was no reason she did not separate the buttocks and labia when she wiped Resident #135 at first. WFM YY stated if Resident # 135 was not completely cleaned, the resident could develop an infection, rashes, and skin breakdown. 676356 Page 11 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 12/30/22 beginning at 9:05 a.m., the DON stated WFM YY should have separated Resident #135 labia and wiped three times with three different wipes; the buttocks should be separated so the rectum area would be cleaned. DON stated Resident #135 should be cleaned thoroughly to make sure all the regions were clean to prevent infection. Record review of the facility policy on incontinence and catheterization dated Februaryn 2017 read in part . 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 . . 676356 Page 12 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (Resident #16) of 6 residents reviewed for pharmacy services. RN E did not administer Humulin N insulin to Resident #16 as ordered by the physician. Resident #16 had medication at the bedside and did not have an order to self-administer medication. These failures could place residents at risk of not receiving the therapeutic outcomes, increased side effects, or a decline in health. Findings included: Record review of Resident #16's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included: acute pancreatitis (a disease condition characterized by inflammation of the pancreas.), type 2 diabetes, and gastrostomy status (a surgical opening into the stomach). Record review of Resident #16's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. She needed extensive assistance of 1-2 staff for bed mobility, transfers, eating, and toilet use. She had a feeding tube. Record review of Resident #16's care plan dated 12/13/22 revealed the resident had diabetes and was at risk for complications associated with diabetes. Interventions were to administer medications as recommended by doctor. There was no documentation in the care plan on self-administration of medications. Record review of Resident #16's order summary report for December 2022 revealed orders for Humulin N 100 units/mL (insulin NPH) inject 3 units subcutaneously two times a day for diabetes mellitus before meals, order date 12/8/22. There were no blood sugar parameters or order to hold the blood sugar. Zenpep delayed release particles 5000-24000 unit give 2 capsules via PEG-tube every 6 hours for enzyme, order date 4/6/22. There was no order for self-administration of medications. Record review of Resident #16's licensed nurse administration record for December 2022 revealed Humulin N was scheduled for 7:30 a.m. and 4:30 p.m. There was a 9 documented by RN E on 12/28/22 at the 7:30 a.m. administration time. A 9 indicated other: nurse verbally informed. Record review of Resident #16's progress note dated 12/28/22 at 2:17 p.m. written by RN E read in part, .Humulin N inject 3 units subcutaneously two times a day for dm (diabetes) for 30 days BID before meals . BS 94 held . There was no documentation to note that the MD was notified. In an observation and interview on 12/28/22 at 9:09 a.m., RN E entered Resident #16's room and checked her blood sugar. RN E said the residents blood sugar was 94 and said she would not receive any 676356 Page 13 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some insulin. There was a white capsule with the writing Aptalis 5 in a medication cup on the bedside table that was in reach of the resident. RN E removed the medication from the room. Upon return to RN E's medication cart there was no computer present to review physician orders or document Resident #16's blood sugar. In an interview on 12/28/22 at 9:14 a.m., RN E said the white capsule removed from Resident #16's bedside was Zenpep (a prescription medicine for people who cannot digest food normally because their pancreas does not make enough enzymes). She said she was not the person who left the medication at the bedside since she had not administered the resident's morning medications yet. She said the resident received her medications via g-tube. In an interview on 12/28/22 at 9:17 a.m., Resident #16 said she saw the capsule on the bedside table but did not know what it was for or who left it there. She said she could swallow small pills but not big ones. Attempted interview on 12/30/22 at 10:18 a.m. the DON along with the Surveyor called RN E. The DON left a voicemail to return her call. In an interview on 12/30/22 at 10:21 a.m., the DON said if there was no order to hold the insulin for Resident #16 the nurse should have completed an assessment and let the MD know that she did not believe the insulin should be given. She said it was a missed dose because of nursing assessment and judgement but the communication should be documented. In an interview on 12/30/22 at 10:52 a.m., the DON said staff were not supposed to leave medication at the bedside unless a self-administration for the resident was done. She said she did not think Resident #16 self-administered medications. She said if a medication is not given it should be taken out of them room with the staff. She said Resident #16 had a feeding tube but was unsure if she took medications by mouth or by g-tube. She said medications should not be left in the room because it was not safe for the residents to have medications at the bedside. She said Resident #16 could choked on the pill. In an interview on 12/30/22 at 2:08 p.m., the DON said the reason to have the electronic MAR present while administering medications is because it had the doctors' orders in it. She said a nurse could miss something, not follow the orders, or administer a medication incorrectly. She said documentation told what you did, why, and when. She said nursing staff should document after each care task or medication administration. She said RN E never returned her call. Record review of the facility's Medication Administration policy dated March 2019 read in part, .Resident medications are administered in an accurate, safe, timely, and sanitary manner . 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route . 7. Observe that the resident swallows oral drugs. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication . Record review of the facility's Pharmacy Services: Provision of Medications and Biologicals policy dated 2/2017 read in part, .The community provides routine and emergency medications and biologicals to its residents or obtains them under an agreement . All medications and biologicals are stored in locked compartments with proper temperature controls and access limited to authorized personnel only . Self-administration of medications: The resident has the right to self-administer medications if the interdisciplinary team has determined this is a safe practice and a comprehensive plan is 676356 Page 14 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 developed . Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Some 676356 Page 15 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0759 Ensure medication error rates are not 5 percent or greater. 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 that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 10% based on 3 errors out of 30 opportunities, which involved 3 of 6 residents (Resident #52, #65, and #66) reviewed for medication errors. Residents Affected - Some - RN E did not administer Furosemide (a medication that helps the body get rid of extra water) to Resident #52. - LVN P administered expired Insulin aspart to Resident #65. - MA A administered four drops of Cyclosporine eye drops in each eye instead of one drop in each eye as directed by the physician for Resident #66. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: Resident #52 Record review of Resident #52's face sheet revealed an [AGE] year-old female admitted on [DATE]. Her diagnosis included: cerebral infarction (stroke), dementia, atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), type 2 diabetes, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction affecting left non-dominant side, hypertension (high blood pressure), major depressive disorder, and unspecified intellectual disabilities. Record review of Resident #52's quarterly MDS assessment dated [DATE] revealed a staff assessment for mental status was conducted. The resident's cognitive skills for daily decision making was severely impaired. She was totally dependent on one staff for dressing and eating; and two staff for transfers and toilet use. She required extensive assistance of one staff for personal hygiene and two staff for bed mobility. Record review of Resident #52's order summary report for [DATE] revealed an order for Furosemide 20 mg give 20 mg via g-tube one time a day for fluid retention, order date [DATE]. Record review of Resident #52's licensed nurse administration record for [DATE] revealed Furosemide 20 mg was documented as administered on [DATE] at 8:00 a.m. by RN E. In an observation and interview on [DATE] at 10:46 a.m. RN E prepared Resident #52's medication for administration via g-tube. She prepared Hydralazine 50 mg (1 1/2 tablet), chewable Aspirin 81 mg (1 tablet), Omeprazole 20 mg (2 capsules), Diltiazem 120 mg (1 tablet), Lisinopril 20 mg (1 tablet), and Sertraline 25 mg (1 tablet). RN E said she had a total of 6 medication cups and administered the medication to Resident #52 via g-tube. RN E did not administer Furosemide 20 mg as ordered by the physician. 676356 Page 16 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on [DATE] at 4:14 pm RN E said Lasix (Furosemide) 20 mg was to be administered during the morning medication pass. She said the eMAR notified her of the medications needed and would prompt her on what to give at a certain time. She said she remembered having 6 medication cups. She said she thought she administered the Lasix but was nervous and was talking to the Surveyor. She said she would notify the MD of the missed medication and ask if it was ok to give. She said the resident was receiving the Lasix for fluid restriction and said there was no risk to the resident for not receiving the medication. In an interview on [DATE] at 10:21 a.m. the DON said nursing staff were trained to look at the blister pack and match the eMAR for dosage, route, frequency, and medication name. She said staff were expected to give medication as ordered by the physician and if they did not it was a medication error. She said that a medication given several hours after the scheduled time was also a medication error. Resident #65 Record review of Resident #65's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included: diabetes mellitus, unspecified dementia, seizures, hypertension, overactive bladder, and altered mental status. Record review of Resident #65's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 out of 15 which indicated severe cognitive impairment. She required extensive assistance of 1 staff for bed mobility, dressing, and personal hygiene. She was totally dependent on 1-2 staff for transfers and toilet use. Record review of Resident #65's care plan dated [DATE] revealed the resident had Diabetes Mellitus. The intervention was to take diabetes medication as ordered by the doctor. Record review of Resident #65's order summary report for [DATE] revealed an order for Novolog penfill solution 100 unit/ml (insulin aspart) inject as per sliding scale: 0 - 150 = 0; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 + = 8 over 300 8 units subcutaneously before meals and at bedtime related to other specified diabetes mellitus, order date [DATE]. Record review of Resident #43's licensed nurse administration record for [DATE] revealed 8 units of Novolog was administered to Resident #43 by LVN P on [DATE] at the 11:00 a.m. scheduled time. In an observation on [DATE] at 11:50 a.m. LVN P checked Resident #43's blood sugar which was 340. She prepared 8 units of Insulin aspart for administration. The open date written on the insulin pen was 11/25. LVN P entered the room and administered the insulin to Resident #43. In an interview on [DATE] at 12:00 p.m. LVN P said 11/25 was the date the insulin pen was opened. She said she would discard the pen because it was only good for 1 month and was two days past. She said they were not supposed to use insulin past the date and said she did not have an answer as to why she used the pen. She said she checked the medication cart daily for expired insulin. She said after the pen went past the allotted timeframe, they discarded it and got a new one from the refrigerator. She said she was unsure of the potential risk to the resident but would find out from the pharmacy. 676356 Page 17 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on [DATE] at 3:04 p.m. LVN P said the pharmacy reported the insulin became less effective when used past the date (28 days after the open date) but should have no effect on the resident unless it was cloudy. In an interview on [DATE] at 10:21 a.m. the DON said insulin pens were good for a certain period and needed to be thrown away and reordered if expired. She said nurses should not use expired insulin pens because it may have a weakend effect. Record review of the facility's Insulin Beyond Use Dates policy dated [DATE] read in part, .Name of Insulin: Novolog flexpen (aspart), Beyond Use Date After Opening at room temp: 28 days . Resident #66 Record review of Resident #66's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnosis included: dry eye syndrome, dementia, type 2 diabetes, and hypertension. Record review of Resident #66's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. She required extensive assistance of one to two staff for bed mobility, dressing, and personal hygiene and was totally dependent on two staff for transfers and toilet use. Record review of Resident #66's order summary report for [DATE] revealed an order for Cyclosporine emulsion 0.05% instill 1 drop in both eyes two times a day for dry eyes due to inflammation, order date [DATE]. In an observation on [DATE] at 8:16 a.m. MA A prepared Resident #66's morning medications for administration. She prepared Restasis (Cyclosporine) eye emulsion, Aspirin, Loratadine, Gemtesa, Divalproex, Metoprolol, Famotidine, Sertraline, Prednisone, Clopidogrel, Bumetanide, Linzess, Cranberry, and Lidocaine patch. She entered the room and began administering the medication. MA A inserted 2 drops of Cyclosporine in each of Resident #66's eyes. She then administered 2 more drops into each of resident's eyes for a total of 4 drops per eye. In an interview on [DATE] at 8:25 a.m. MA A said she administered 4 drops of Cyclosporine in each of Resident #66's eyes until the single use vial was empty. She said the directions said to administer one drop per eye, but she used the entire vial. She said the amount of medication in the single use vial was so tiny and she did not think anything would happen to the resident if she administered more than one drop. She said the eye drops were indicated for inflammation. She said she referenced the medication MAR to obtain the directions, medication name, and image of medication. In an interview on [DATE] at 10:21 a.m. the DON said she expected staff to give the medication Restasis as ordered by the physician which was one drop in the right eye and one drop in the left eye. She said nursing staff were not medical doctors and would not know what the outcome would be if not given as ordered. Record review of the facility's Pharmacy Services: Provision of Medications and Biologicals dated Febuary 2017 read in part, .Medication errors: medication errors include, but are not limited to administering the wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route, omitting a medication, and/or administering to the wrong resident . 676356 Page 18 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0759 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Medication Administration policy dated [DATE] read in part, . Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner . Responsible Disciplines Licensed Nurses, C.M.A.'s . 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route . Residents Affected - Some . 676356 Page 19 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food service safety, in that: -Three dented cans were on the can rack located in the dry storage room. -1 box of chips were on the floor in the dry storage room. -4 plastic containers of potentially rotten or expired fruit was present in the walk-in cooler. This failure could place residents at risk for cross-contamination and foodborne illnesses. Findings include: Observation of the kitchen on 12/27/2022 at 8:20 am., revealed 3 dented cans on the shelf with the non-dented cans and one box of Frito Lays chips observed on the floor in the dry storage room. One plastic container of strawberries and 3 plastic containers of blueberries were observed with a white fuzzy residue in the kitchen cooler. Interview on 12/27/2022 at 8:31 a.m. with [NAME] B, she stated she had been employed at the facility for 2 years. She stated fruit was ordered 3 times a week, she stated the fruit was supposed to be checked daily by kitchen staff. [NAME] B observed the strawberries and blueberries and stated the fruit was molded. She stated the staff could not have checked the fruit due to the mold. She stated all old and molded fruit was supposed to be removed from the refrigerator and thrown away. She stated the tray aids were responsible for checking the fruit daily and ensuring that all old items were discarded. She stated the risk of not discarding old fruit was it could cause stomach problems for the residents and contamination of other fruit. Interview on 12/27/2022 at 8:50 a.m. with the Dietary Supervisor, she stated it was the responsibility of all kitchen staff to check the cooler for expired foods and ensure food is not stored on the floor. She stated the cooler was to be checked daily. She stated the risk of having expired foods was that it could cause residents to become sick. The Dietary Supervisor stated all dented cans was supposed to be placed in a separate pile from non-dented cans. She stated foods was not supposed to be placed on the floor and reported that the staff placed the food on the floor when they were unloading the food and had forgotten to put it away. She stated the risk of having dented cans and food on the floor could mean that things are spoiled, it could cause insects or rodents and contamination of the food items. Record review of the facilities survey prep to do's dated 08/13/2022 stated inspect all produce 3xweek for spoilage and discard expired items. A copy of the policy and procedure for the kitchen food storage was requested from the Dietary Manager on 12-27-22 at 9:05 a.m. and on 12-29-22 at 2:30 p.m. but not provided before exiting the facility. . 676356 Page 20 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. Residents Affected - Many -The facility failed to ensure the dumpster lids and doors were secured. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. Findings include: An observation on 12/27/22 at 8:46 a.m., revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial-sized dumpster ¾ full of garbage and the lid was open. Interview on 12/27/22 at 8:50 a.m., with the Dietary Supervisor she said the dumpster lids must always be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She acknowledged that the dumpster lids must have been left opened by the last staff who used the dumpster. She stated it was the responsibility of all staff to ensure the lids were closed after using the dumpster. A copy of the policy and procedure for the waste disposal was requested from the Dietary Manager on 12/27/22 at 9:05 a.m. and on 12/29/22 at 2:30 p.m. but not provided before exiting the facility. . 676356 Page 21 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 6 residents (Resident #10, #26, #29, #40, #75, and #135) reviewed for infection control. Residents Affected - Some -CNA C failed to change gloves and wash or sanitize her hands when moving from a dirty area to a clean area when providing incontinent care to Resident #10. -CNA AA failed to change gloves and wash or sanitize her hands when moving from a dirty area to a clean area when providing incontinent care to Resident #29. -CNA BB failed to change gloves when providing wound care to Resident #26. -The facility failed to ensure CNA T properly used infection control procedure during wound care when she placed the Foley bag on the bed at the same level as the bladder for Resident #40. -The facility failed to ensure CNA T properly used PPE during wound care when she donned gloves she took from her uniform pocket for Resident # 75. -The facility failed to ensure CNA AA properly performed hand hygiene and infection control procedure during bed linen change for Resident # 135. -The facility failed to ensure WFM YY used proper infection control procedure during incontinent care for Resident #135. -The facility failed to ensure Housekeeping A properly used PPE during trash pickup from a resident's room. -The facility failed to ensure the ADON properly carried used disposable gown out of a resident's room. These failures could place residents who required incontinent care and wound care at risk for cross contamination, infection, delay in treatment and hospitalization. Findings include: Resident # 10 Record review of the admission sheet for Resident # 10 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included bacterial infection unspecified, (occurs when bacteria enter the body, increase in number, and cause a reaction in the body), chronic kidney disease stage 3 (gradual loss of kidney function with mild to moderate damage), hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness on one side of body caused by condition or injury). Record review of Resident #10's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 676356 Page 22 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0880 Level of Harm - Minimal harm or potential for actual harm 15 out of 15 indicating the resident was cognitively intact. She required extensive 1-2-person assistance with her activities of daily living, which may include: bathing/showering, dressing, grooming, personal hygiene, toileting, medication administration, and mobility. She was incontinent of bowel and bladder. Record review of Resident # 10's care plan initiated 12/15/21 revealed the following care plan: Residents Affected - Some Focus: Resident has frequent bladder incontinence r/t loss of peritoneal tone. Goal: Risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI. Interventions: Wash, rinse, and dry soiled areas. Change clothing prn after incontinence episodes. Record review of Resident #10's Physician orders dated November 26, 2022, read in part . Amoxicillin-Pot Clavulanate Tablet 500-125 MG, Give 1 tablet by mouth three times a day for bacterial infection for 10 days-Start date 11/26/22 0800. Interview on 12/27/22 at 9:54 a.m., Resident # 10 stated her brief was wet and she was waiting for staff to come in and change her. Resident # 10 said she had worked as a CNA before she had a stroke and she felt bad depending on staff for help. Observation on 12/27/22 at 10:18 a.m., revealed CNA C provided incontinent care to Resident #10. CNA C with assistance from CNA L turned Resident #10 onto her left side to clean her buttocks. CNA C removed Resident #10's brief and tucked it under the resident's buttocks and used the same wipe to clean her labia and buttocks. CNA C removed the soiled brief and discarded it into the clear plastic bag sitting near the resident's foot of bed. CNA C during incontinent care did not change gloves, or wash or sanitize her hands and continued with incontinent care. CNA C completed incontinent care and with the same soiled gloves touched the resident's clean brief and placed it on the resident's bottom. In an interview on 12/27/22 at 10:32 a.m., CNA C, stated she started working full time at this facility two months ago. She said she forgot to properly clean the resident. She said she should have washed her hands or used hand sanitizer before and after removing her gloves while providing care to Resident #10. She said the failure placed the resident at risk for infections and germs. During an interview on 12/27/22 at 10:41 a.m., the DON said all staff had to perform hand hygiene before and after resident care and in between all glove changes. The DON said the risk of not performing hand hygiene is spreading infections. Resident #29 Record review of the admission sheet for Resident #29 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included paraplegia, unspecified (paralysis of lower extremities), neuromuscular dysfunction of bladder, unspecified (lack of bladder control due to brain, spinal cord, or nerve problems). Record review of Resident #29's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating the resident was cognitively intact. He required extensive 1-2-person assistance with his activities of daily living, which may include: bathing/showering, dressing, grooming, 676356 Page 23 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0880 personal hygiene, toileting, and medication administration. The MDS indicated he was incontinent of bowel and bladder. Level of Harm - Minimal harm or potential for actual harm Record review of Resident # 29's care plan initiated 12/19/22 revealed the following care plan: Residents Affected - Some Focus: Resident require a catheter indwelling catheter. Goal: I will not experience any complications associated with my catheter to include trauma, infection or pain, dignity concerns through my next review date. Interventions: Monitor for s/sx of discomfort and abnormalities report those findings to MD as indicated. Observation on 12/28/22 at 10:09 a.m., revealed CNA AA provided incontinent care to Resident #29. CNA AA removed Resident #29's brief and tucked it under the resident's buttocks. CNA AA assisted Resident #29 to turn onto his left side to clean his buttocks. CNA AA removed the soiled brief and discarded it into a plastic waste container sitting near the side of the resident's bed. CNA AA during care did not change gloves, wash, or sanitize her hands and continued with incontinent care. CNA AA used the same washcloth to clean resident's peri area, scrotum and then touched an open wound area with the same washcloth. CNA AA completed incontinent care and with the same soiled gloves touched the resident's clean brief and placed it under his bottom. During an interview on 12/28/22 at 10:32 a.m., CNA AA, stated she was an agency staff. She said she should have washed her hands or used hand sanitizer before and after removing her gloves while providing care to Resident # 29. She said the failure placed the resident at risk for infections and cross contamination of his wound. In an interview on 12/28/22 at 12:07 p.m., with the DON, she said she expected staff to provide appropriate care to residents based on their needs. She said the CNA should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care and in between all glove changes. She said the staff should wash their hands when entering a resident's room if they were going to provide any care. Resident #26 Record review of Resident #26's face sheet revealed a 66 -year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were,), hypertension (persistently raised blood pressure), cerebral infraction (narrowing of the artery that supply blood and oxygen to the brain, which causes necrotic tissue of the brain.), hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body) and diabetes mellitus( the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced). Record review of Resident #26's annual MDS assessment, dated 12/12/22, revealed a BIMS of 14 indicating intact cognition. Further review revealed Resident #26 needed total assistance with ADL care with one to two staff assistance and the resident was incontinent of bowel and bladder. Record review of Resident #26's care plan dated 1/4/21 revealed the resident had an alteration in elimination related to bowel/bladder incontinence. 676356 Page 24 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation on 12/30/22 at 11:53 a.m., revealed CNA BB assisted Resident #26 when she left, went to her roommate's section still wearing the same gloves, arranged items on her bedside table, and pushed the table across the roommate's bed. Then she returned and continued to assist the nurse with Resident #26 wound care, still wearing the same gloves. In an interview on 12/30/22 at 12:47 p.m., the administrator said CNA BB should have taken the gloves off when she left Resident #26 section before she went to her roommate, arranged her bedside table, and moved it across the bed. She also said she should have taken her gloves off, sanitized or washed her hand, and donned another pair of gloves before she returned to Resident #26. In an interview on 12/30/22 at 2:05 p.m., CNA BB said she was assisting Resident # 26 when she left and went to her roommate section and arranged her bedside table before she moved it across her because it was on her way but did not remove, CNA BB stated she used the same which was used on Resident #26 before she touched her roommate's personal. As a result, she could have contaminated her roommate with Resident #26 germs. She also stated she went back to Resident #26 and continued to assist with wound care with the same gloves, and she could have transferred the germs from her roommate's items to Resident # 26. Resident #40 Record review of Resident #40's face sheet revealed a [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Her diagnoses was morbid, severe obesity (a complex chronic disease in which a person has a body mass index (BMI) of 40 or higher or a BMI of 35 or higher and is experiencing obesity-related health conditions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), urinary tract infection, and retention of urine (a condition in which urine cannot empty from the bladder). Record review of Resident #40's Care Plan revised on 11/04/22 read in part . Resident #40 will remain free from catheter related trauma. Foley Catheter with perineal wipes and or soap and water. Q shift and PRN and activate task on POC every shift for pain. Bed mobility X1 person assistance as needed only. Hygiene 1 require 1 staff assistance for hygiene ADL's. Dressing and grooming X1 person assistance . Record review of Resident #40's Comprehensive MDS dated [DATE] revealed Resident #40 had a BIMs score of 04 indicating the resident was severely cognitively impaired. The resident required one person assist with toileting. The MDS noted the resident was incontinent of bowl and had a Foley Catheter. The MDS Preferences for Customary Routine and Activities section noted it was very important to Resident #40 to choose what clothes to wear and to choose between a tub bath, shower, bed bath, or sponge bath. During an observation and interview on 12/30/22 at 2:40 p.m., it revealed Resident # 40 was provided wound care by the treament nurse and assisted by CNA T. CNA T placed the Foley bag on the bed before the resident was turned to her side and the foley bag was left on the bed throughout the care which was for 14 minutes. CNA T said the urine flowed back to the resident bladder. The treatment nurse said the urine flowed back into the resident bladder because it was at the same level as the bladder and could cause infection. She said she just noticed the bag was on the bed now. In an interview on 12/30/22 at 3:11 p.m., CNA T said she placed Resident #40's Foley bag on the bed 676356 Page 25 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because she did not want the bag to hit the floor,she stated the urine flowed back into the bladder. She said she was unsure what could be a negative outcome for Resident # 40 when urine flowed back into the bladder. CNA T said she had in-service on how to take care of a resident with Foley but was not told the Foley bag could not be placed on the bed during in-service or how it would cause harm to the resident if it paced on the same leave as the bladder. She said she was though how to clean the Foley catheter from the vagina downward. In an interview on 12/30/22 at 3:20 p.m., the DON said CNA T should not have placed the Foley bag on the same level with the bladder because the urine would follow back to Resident #40'S bladder. She also said it could cause a bad bacterial infection. she stated how to place a foley bag and the reasoning should be part of the Foley care in-service. Resident #75 Record review of Resident #75's face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, hypertension (persistently raised blood pressure), atrial fibrillation (irregular heartbeat, heart beats faster than normal) and need for assistance with personal care. Record review of Resident #75's care plan dated 11/03/22 revealed the resident had ADL (activity of daily living) self-care performance deficit related to pain in left hip. Intervention: resident needed extensive assist with two-person assistance with toilet use. It also revealed pressure ulcer or potential for pressure ulcer related to incontinent of bowel and bladder. MASD (moisture related skin damage) stared on 11/08/22, skin fragile and at risk for injury - new or worsening skin condition. Interventions: apply treatment s ordered, keep skin clean and dry and apply skin barrier cream as indicated. Record review of Resident #75's admission MDS assessment, dated 10/31/22, revealed a BIMS score of 11 indicating moderately impaired cognition. Further review revealed Resident #75 needed extensive assistance with ADL care with one staff assistance and the resident was incontinent of bowel and bladder. Record review of Resident #75's Braden scale dated:10/30/22, 11/06/22, 11/22/22, 11/26/22 read Resident #75 score was 14 which indicated moderate risk for pressure sore risk while 12/28/22 read score was 15 at risk for pressure sore risk. Record review of Resident #75's skin and total body skin assessment dated : 10/24/22, 10/31/22, 11/16/22, 11/21/22, 12/05/22, 12/14/22 and 12/19/22 revealed there was no new wounds. Record review of Resident #75's order summary report dated December 2022 revealed there was no order for MASD. An observation on 12/30/22 at 2:58 p.m., revealed that CNA T assisted with Resident # 75's wound care treatment. CNA T took gloves from her uniform pocket, donned them, helped the resident to the side, held him while wound care was provided, and assisted back after wound care. In an interview on 12/30/22 at 3:16 p.m., CNA T said she used the gloves from her pocket while she assessed Resident #75 wound care. She stated she knew not to put gloves in her pocket but did it for convenience. CNA T said she did not understand why she should not have used the gloves from her 676356 Page 26 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pocket. CNA T said she had in service on hand washing, donning, and doffing of PPE, and it did not mention anything about not using gloves from her uniform pocket. In an interview on 12/30/22 at 3:24 p.m., the DON said CNA T should not carry gloves in her uniform pocket or use it on Resident #75 because you do not know what was in her uniform pocket, she said she could transfer her germs to the resident. Resident #135 Record review of Resident #135's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Resident #135's diagnoses was hypertension (a condition in which the force of the blood against the artery walls is too high), symptoms and signs involving musculoskeletal system (the performance of the locomotor system, comprising intact muscles, bones, joints, and adjacent connectives tissues), need for assistance with personal care, bone density and structure, atherosclerotic heart disease (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow). Record review of Resident #135's care plan dated 11/04/022 read in part . prefers to be showered 2-3 times weekly (date initiated on 12/24/2022). Resident #135 has a self-care deficit r/t weakness (date initiated on 12/24/2022). Resident #135 care plan also revealed she may be at risk for self-care deficit, falls, skin concerns, pain, infection and nutritional/hydration concerns and emotional distress. Dressing and grooming X1 person assistance (date initiated on 12/24/2022). Resident #135 has a self-care deficit r/t weakness, and she may be at risk for self-care deficit . Record review of Resident #135's Comprehensive MDS dated [DATE] revealed Resident #135 was a new admission. There were no BIMS noted. During an observation on 12/28/22 at 2:54 p.m., CNA BB striped the linens from Resident # 135's bed and placed them on the floor. She later put the linens in the trash bag, took off her gloves, and left the room without washing or sanitizing her hands. In an interview on 12/29/22 at 4:20 p.m., CNA AA said she did not wash her hand before she donned her gloves. CNA AA said she should have washed her hand or used sanitizer before donning her glove to prevent the spreading of germs, and she forgot to wash her hands when she took off her gloves before she left Resident #135 room. She said she placed the linen on the floor, and she should not have because it was cross-contamination. She said she was trained in infection control by her agency. In an interview on 12/30/22 at 9;24 a.m., the DON said when CNA AA stripped Resident # 135's bed linens, she should have placed it in the trash bag, not the floor, then put it on the chair and taken it to the dirty utility room aftercare was provided for Resident # 135. she said it was infection control issue because bacteria could spread from one area to another. Additionally, DON said CNA AA should have washed her hand before donning her gloves to provide and washed her hands before she left the resident's room because you do not take the germs from one room to another. In an interview on 12/30/22 at 12:42 p.m., the Administrator said CNA AA should have washed her hands after she took off her gloves before she left Resident # 135's room to prevent the spread of germs from one resident to another. In addition, he said the linens should not be put on the floor because it is cross-contamination. He also said she should have washed her hand before she donned her gloves. 676356 Page 27 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation on 12/29/22 at 3:24 p.m., revealed Resident # 135 was provided incontinent care by WFM YY and was assisted by CNA AA. WFM YY did not separate the resident's labia or buttocks. Resident #135 was turned to the left, and she wiped the right buttock but did not wipe the left buttock. WFM YY was about to apply the clean incontinent brief when the surveyor intervened; when she separated the labia and buttocks and wiped each area three times, she wiped out bowel movement three times from the labia and the rectal area. WFM YY applied hand sanitizer twice during incontinent care; she robbed her hands a couple of times, then she waved her front and back. She stated she was trying to dry her hands quickly. In an interview on 12/29/22 at 4:00 p.m., WFM YY said she applied hand sanitizer two times during Resident #135 incontinent care. She fanned her hands two separate times for her hands to dry quickly, she said hands should be rubbed together until dry to kill the germs. She said she wiped out bowel movements from the labia and buttocks' when she separated the areas. WFM YY said there was no reason she did not separate the buttocks and labia when she wiped the resident. She said if Resident # 135 was not completely cleaned, the resident could develop an infection, rashes, and skin breakdown. In an interview on 12/30/22 at 9:05 a.m., the DON said WFM YY should have separated Resident #135 labia and wiped three times with three different wipes; the buttocks should be separated so the rectum area would be cleaned. She said Resident #135 should be cleaned thoroughly to make sure all the regions were clean to prevent infection. During an observation and interview on 12/28/22 at 2:59 p.m., it revealed Housekeeping A came out of a resident room with a trash can and placed the trash can beside the room, and she took the trash bag from the can. At the same time, she wore the used gloves, walked three rooms down, and placed the trash into the trash can attached to her cart. Housekeeping A was about to push the cart away, still wearing dirty gloves, and the surveyor intervened. Housekeeper A said she was not supposed to come out of the resident's room with gloves on to prevent cross-contamination. She said she had hand washing and infection control in-service, including PPE. In an interview on 12/30/22 at 10:05 a.m., the Account manager said Housekeeping A should have placed her cart by the resident door where she picked up the trash and put the trash bag in the cart trash can, taken off her gloves, and sanitized her hand. she said she should not have worn the used gloves on the hallway because of infection control issue. In an interview on 12/30/22 at 12:20 p.m., the Administrator said the housekeeping usually wore gloves in the hallway when they handled chemicals. The administrator said he did not see any issue with Housekeeping A picking up a trash bag from a resident's trash can, walking down the hall to his cart, trashing the bag, and pushing the cart with the same gloves. He said if she had taken the gloves off the gloves and pushed the cart, she would have contaminated the cart. When asked what staff would do when they removed used gloves, he responded to wash or sanitize their hands. When he was asked if hand washing after doffing used gloves applied to housekeeping, he said they are contract workers. He was asked if the housekeeping company signed the facility infection control policy when the company signed the contract with the facility. He said she would check on it and get back to the surveyor. During an observation on 12/29/22 at 3:05 p.m., it revealed ADON was at the door of a resident's room with a yellow disposable gown on, and she took it off by the door and carried the gown out of the resident's room and walked three doors down the hall and she placed it in a biohazard bag attached to a cart that had COVID testing supply. 676356 Page 28 of 29 676356 12/30/2022 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 12/30/22 at 9:30 a.m., the DON said the ADON should not have taken the yellow gown out of any resident room because of infection control. She was administering COVID testing because one resident tested positive. Therefore, the used gown should be disposed of in the resident's room. In an interview on 12/30/22 at 1:17 p.m., the ADON said she should not have taken the gown out of the resident's room because it was contaminated, and she did not what to put the gown in the resident's trash because it would fill up the resident's trash can. She said she had training on donning and doffing PPE. Record review of the facility's policy Infection Prevention and Control Program dated 0/13/19 (revision date: 10/2022) read in part: .Compliance Guidelines: The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection. 7. Prevention of Infection a. Important facets of infection prevention include: (3) educating staff and ensuring that they adhere to proper techniques and procedures. 8. standard precautions . infection control practice . practicing hand hygiene . implementation enhanced barrier precautions . # 8c . have a trash can for discarding PPE after removal, prior to exit of the room . definitions . standard precautions include hand hygiene, proper selection, and use of personal protective equipment . . 676356 Page 29 of 29