Health inspection·March 1, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 3 residents (Resident #13) reviewed for coordination of PASRR and assessments. The facility failed to request, submit and coordinate the PASRR assessment and screening in the Simple LTC portal to ensure therapeutic services (physical, speech and occupational) were completed for Resident #13 . This failure could place residents at risk of not receiving necessary care and services in accordance with individually assessed needs. Findings included: Resident #13 On [DATE] at 1:00 pm a telephone interview with an anonymous person revealed that the facility did not complete and submit PCSP forms to coordinate PT, OT, and ST services for Resident #13. During this interview, it was revealed that Resident #13 did not receive specialized PT, OT, or ST therapies due to this failure. On [DATE] at 8:20 am, an interview with the Director of Rehab, it was revealed that the therapy department fills out a request for specialized services then the MDS Coordinators complete the form, MDS Coordinator A usually submits the therapy documentation for long-term-care. She said that Resident #13 refused PT at one point, and she would try to find the dates for Resident #13's PASRR submissions. On [DATE] at 8:25 am an interview with MDS Coordinator A, it was revealed that PT,OT and ST fill out a request form for specialized services and she was not sure when they filled it out, but she had been in contact with the PASRR representative, and she was aware of the status. An interview on [DATE] at 12:24 pm with the Senior Director of Clinical Reimbursement, it was revealed that Resident #13 refused PT services and that Resident #13 received OT and ST services and never missed treatment even though the request for treatments were not in the portal . Interview on [DATE] at 4:27 pm with MDS Coordinator A, it was revealed that she could not confirm Page 1 of 21 676356 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the habilitative services per Simple LTC portal, that the submitted request for PT was not approved and expired in January of 2023 and the OT and ST submitted request expired in [DATE]. On [DATE] at 1:37 pm with Physical Therapist A, it was revealed that PT, OT, and ST therapist were the ones responsible for completing the assessments, the assessments are then sent to MDS Coordinators, and the Director of Rehab does the rest of the process. It was revealed that the most recent request for PT was last year (date unknown) and they never received authorization and there were new requested submitted on [DATE] for all services (PT, OT and ST). Surveyor B requested to interview the Director of Rehab again to but was informed that she had already caught a flight and was not available. A specific policy and procedure for submitting the PT/OT and ST assessments and request was requested but not received. Record review of Resident # 13's facility admission record dated [DATE] revealed a [AGE] year-old female with an initial admission date of [DATE] and admission date of [DATE] with diagnoses that included cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain), deaf; nonspeaking (deaf people who cannot speak an oral language or have some degree of speaking ability) and Schizoaffective Disorder (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations). Record review of Resident # 13's quarterly MDS dated [DATE] with an ARD of [DATE] revealed a BIMS score of 1, severe cognitive impairment. The MDS revealed Resident # 13 required 2-person assistance with bed mobility, transfers, and ADL's. Record review of Resident # 13's care plan, date initiated [DATE], revised on [DATE] revealed a care plan to address, narrate and document interventions for Resident #13's PASRR needs as follows: Resident was considered PASRR +:Initial Meeting held [DATE] with services of OT and ST recommended and will be initiated. PASRR quarterly meeting held [DATE]. Will continue current plan of care with no changes recommended. Translator was made available. Quarterly PASRR meeting held [DATE]. Continue POC. No changes to report . I will maintain my highest level of functional well-being with regards to my care and any PASRR special services that I may have in place throughout my next review date. Date Initiated: [DATE], Created on: [DATE], Revision on: [DATE] Target Date: [DATE] .Coordinate my plan of care with my Service Coordinator as indicated. Date Initiated: [DATE], created on: [DATE] . Invite my representative and/or responsible party to attend my care plan meeting as scheduled. Date Initiated: [DATE] Created on: [DATE]. Revision on: [DATE] (PASRR) Evaluation Report, date of PASRR Evaluation [DATE], for Resident #13 revealed recommendations for Physical Therapy (PT) Specialized Assessment Speech Therapy (ST), Occupational Therapy (OT) Specialized Assessment Physical Therapy (PT) Speech Therapy (ST) and a Customized Manual Wheelchair (CMWC) in a Nursing Facility setting. Record review of the PASRR Evaluation dated [DATE] requested but the surveyor only received 2 pages which only revealed that Resident #13 was evaluated by a Qualified Intellectual Disability Professional (QIDP) Record review of the SimpleLTC documentation dated [DATE] revealed documentation IDD Specialized Comments read in part .Family/MPOA(Medical Power of Attorney) prefers for Resident #13 to be assessed for Habilitative OT/ST and is not interested in other NFSS, Resident #13 is in agreement. 676356 Page 2 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the NFSS Submissions page in the Simple LTC portal revealed that on [DATE] the assessments and submittal for OT, ST and PT rehab services were performed for Resident #13 and were pending state review. Record review of a screenshot of the NFSS Submissions page in the facility portal revealed that on [DATE] the assessments and submittal for OT, ST and PT rehab services were performed for Resident #13. Record Review of OT Treatment encounter notes dated [DATE] for Resident #13 read in part .patients reported no change in function and precautions are for safety, fall, deaf and mute. Record Review ST Treatment encounter notes dated [DATE] for Resident #13 read in part .patients reported no change in function and precautions are for communication, aspiration, confusion and PEG tube. Record Review of PT Evaluation/Plan of treatment and notes revealed a certification for [DATE] through [DATE] and a PT Discharge summary dated [DATE]. A PT Evaluation and Plan of treatment with a certification period of [DATE] to [DATE]. Observation on [DATE] at 9:52 am Resident #13 was observed to be lying in her bed and appeared to be asleep. Her face was covered with a blanket and a staff member explained that she preferred to sleep with her face covered. The call-light was attached to her bed and within reach. The room appeared to be clean, odorless and her specialized wheelchair was at the foot of her bed. Record review of the facility policy entitled Specialized Rehabilitative Services dated revised [DATE], read in part . Specialized services for MI or MR .for a resident with MI or MR, the community will ensure that the individual receives the services necessary to assist him or her in maintaining or achieving as much independence and self-determination as possible. The Preadmission Screening and Resident Review (PASRR) indicates specialized services required by the resident. The state is required to list those services in the report, as well as to provide or arrange for the provision of the services. Even if the state determines that the resident does not require specialized services, the community is still responsible for providing all services necessary to meet the resident's mental health or mental retardation needs. The community provides interventions that complement, reinforce, and are consistent with any specialized services (as defined by the resident's PASRR). The individual's plan of care specifies how the community integrates relevant activities to achieve consistency and enhancement of PASRR goals. Mental health rehabilitative services for MI and MR may include but are not limited to: consistent implementation during the resident's daily routine and across settings of systematic plans that are designed to change inappropriate behaviors .development, maintenance, and consistent implementation across settings of those programs designed to teach individuals the daily living skills they need to be more independent and self- determining, including but not limited to grooming, personal hygiene, mobility, nutrition, vocational skills, health, drug therapy, mental health education, money 676356 Page 3 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0644 management, and maintenance of the living environment. Level of Harm - Minimal harm or potential for actual harm dated [DATE], read in part . Documenting and Submitting an IDT Meeting into the LTC Portal For an individual with a positive PE portion of the interdisciplinary team (IDT) meeting is held within 14 days of an individual's admission or for a resident review, within 14 days after the LTC Online Portal generates a notification to the LA to complete a PE. The IDT is held to determine whether the individual is best served in a NF or community setting. The IDT is also used to identify which of the recommended specialized services the individual, or LAR on the individual's behalf, wants to receive. The IDT meeting is documented on the PASRR Comprehensive Service Plan (PCSP) Form and information from the PCSP is entered into the LTC Online Portal. Residents Affected - Few 676356 Page 4 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision to prevent accidents for 1 (CR #100) of 1 resident reviewed for adequate supervision. -The facility failed to provide adequate supervision and training of the staff when they incorrectly identified CR #100 as having left the facility with a family member on 05/22/2023 but later identified him as eloped on 05/23/2023. This failure placed residents living in the facility at risk of harm due to avoidable accidents by inadequately monitoring and documenting resident whereabouts, with the potential of the residents eloping from the facility while still requiring care and treatment. This noncompliance was identified as Past Non-Compliant. The IJ began on 5/22/23 and ended on 5/24/23. The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to state entrance. On 02/29/2024 at 10:54 a.m., facility administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the administrator by email. Findings include: Record review of CR #100's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses include cerebral infarction with aphasia, dysphagia, lack of coordination, cognitive communication deficit, depression, and anxiety. Review of CR #100's MDS (Minimum Data Set) dated April 28, 2023, section C revealed a BIMS (Brief Interview for Mental Status) score of 7. Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and one person assisting with bed mobility, transferring and toilet use. It also revealed resident requires limited, one-person assistance with dressing, eating and personal hygiene. Record review of CR #100's care plan dated 05/03/2023 revealed: 1. Focus: I have impaired cognitive function/dementia or impaired thought process r/t (related to) aphasia following acute CVA (cerebral vascular accident, a stroke) . -Goal: I will improve current level of cognitive function . -Interventions: 1. Keep my routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion .2. Ask yes/no questions in order to determine my needs. 2. 676356 Page 5 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0689 I am at risk for discharge concerns r/t resident not able to stay at SNF (Skilled Nursing Facility) Level of Harm - Immediate jeopardy to resident health or safety -Goal: Resident .will not experience AMA (this stands for against medical advice, used when a resident discharges from a health care institution against the advice of their doctor), or will not experience any negative outcomes as a result Residents Affected - Few -Interventions: 1. Coordinate a care plan meeting as indicated. Include resident/patient and representative as indicated. 2. Refer to Social Services as needed. Record review of CR #100's progress notes dated 5/22/23 revealed RN B recorded resident as D/C (discharged ) home but no nurse progress notes or documentation detailing where the resident went to after he was last seen at the facility on 5/22/23. Record review of facility's grievance log from March 2023 to February 2024 revealed no concerns from CR #100 or family members. Record review of the facility's daily staffing sheet for May 22, 2023, when CR #100 eloped from the facility revealed that LVN C was working on resident's hall on day shift and RN B was working on resident's hall on night shift. Record review of LVN A's statement dated 5/23/23 revealed that she received a report from the day nurse LVN B that two residents had discharged , including CR #100, and when she walked the hall with the nurse both of them saw nobody in resident's room. LVN #1 said she never set her eyes on the resident and relied on LVN B's statement and discharged the resident in PCC, charting that he went home. Record review of CNA A's statement dated 5/23/23 revealed she last saw CR #100 around 6:50pm, as he was going towards the front of the building. When she asked where he was going, he said he was going to meet his wife. CNA A stated resident was acting normally. She saw him with a pullup in his hand. She told resident's nurse he was going to wait for his wife in the front lobby and she went to talk to him. Interview with CR #100's wife at 2/27/24 at 12:44pm, she said staff told her CR #100 informed them he was waiting for someone, but the wife told the staff she did not know anyone by the name CR #100 provided. She said she did not have transportation at the time so would not have been able to visit. She said CR #100's cognitive memory was 50% and he could not walk well. She said the police found CR #100 around a week and a half later sitting on his rollator, and that he was dirty and had lost his phone. The hospital informed resident's wife he had a diaper rash. She said the facility's told her their cameras face the front and did not capture him leaving. She said he never exhibited exit-seeking at his previous facilities. Interview with DON on 2/28/24 at 3:30pm, she last saw CR #100 sitting at the front entrance on 5/22/23 between 6-6:30pm. Resident #1 told her that his wife was coming to pick him up. DON said resident was pleasant and said he had eaten when asked. She didn't think nothing of it and trusted his nurse would sign him out on pass. When she came to work the following morning on 5/23/23, DON found out resident was marked as discharged in PCC. When she looked at his records, she did not locate any discharge paperwork. When she interviewed the nurse who worked the day shift of 5/22/23 , she said she thought the resident was leaving on pass. When she talked to the night nurse who took over the shift, she reported the day nurse told her the resident had been discharged . The night nurse marked the 676356 Page 6 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident as discharged in the system. The DON said when she found out the resident was missing, she called a Code Pink, and the staff members did a full search of the facility and surrounding area by foot and car. The search was unsuccessful, so the Administrator notified the police for assistance. The DON also called CR #100's wife, who said resident is upset at her for not letting him come home and won't take her calls. The wife told the DON he has eloped multiple times before, but that she never told anyone at this facility. The DON then called resident's doctor who said resident is alert and oriented and therefore able to make the decision to discharge AMA. The DON called nearby shelters and hospitals. The facility conducted interviews of staff who worked with the resident on 5/22/23, including LVNs, CNAs, and housekeeping regarding resident's behavior. The DON said that LVN B was an agency nurse and did not return to the facility after 5/22/23 so she was unable to collect a witness statement. The facility reviewed cameras but was not able to see the resident exit the building. Based on the doctor's conclusion resident left AMA , the facility ended the search since he was able to leave on his own. When asked what should have been done, the DON said the nurses should have checked the sign-out binder, called the DON to confirm and reviewed PCC for discharge orders. During another interview with the DON on 2/29/24 at 9:50am, she stated the facility has not used agency staff since September 2023. She said the facility conducted in-services after the resident left, including rounding and census count during shift change, signing out residents, codes and elopement drills, anticipating elopement risk and identifying exit-seeking behaviors. She also said discharges are discussed during morning daily clinical meetings and that nurses receive resident discharge packets for the day so that staff are kept in the loop. She also said after the incident, nurses are required to provide a full 24-hour report both written and verbal. Interview with [NAME] County Police Department on 2/28/24 at 8:00am, the representative stated that a formal request for the police report on CR#100's missing persons case would need to be filled out and submitted to the legal department. The form has been submitted and is pending as of 03/12/2024. Attempted interview with RN B on 2/28/24 at 4:20pm and a voicemail was left. Attempted interview with LVN C on 2/28/24 at 1:01pm, LVN C was the one of the last staff to see resident at the facility. LVN C hung up after introduction. LVN C did not answer during the second attempt at 1:03pm; a voicemail was left. Interview with CR #100's physician on 2/29/24 at 11:44am, he stated that he had 4 visits with the resident between April and May 2023. He stated the resident was pretty stable, medically stable and that his visits were uneventful but that he left AMA (against medical advice). After the resident eloped, the DON called him regarding resident's right to leave. The physician said he told her he thought the resident could make his own decisions and therefore felt he was competent enough to leave on his own. When asked what his visits with the resident was like, the physician said he felt the resident was lucid and oriented every time he talked to the resident. He said during the last two visits with physician's NP, the resident could ambulate 150 ft (feet) with supervision. Physician did mention towards the end of his stay the resident was refusing physical therapy. Interview with the SW on 2/28/24 at 2:12pm, she said she conducts the BIMS score for residents. She said that CR #100 had a cognitive deficit, and she documents her assessments in PCC. She said that the resident never expressed wanting to leave the facility. She said she conducted initial social services assessments mainly with resident's wife. 676356 Page 7 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Interview with RN A on 2/28/24 at 9:19am, she said she did not know the resident. She said residents are assessed for elopement during admission and if they exhibit exit-seeking behaviors, such as saying I don't belong here or I don't belong here. If that happens, RN A will conduct an assessment and tell the DON who will conduct her own assessment for residents. She said she had elopement and Code Pink training in February. If residents are missing, staff will search each hall. If residents have a wanderguard it will sound an alarm. If residents aren't found after the search, staff will tell the Administrator and DON. Residents Affected - Few Interview with LVN A on 2/28/24 at 1:12pm, they stated they did not know Resident #1 since they work on a different hall. They said they have in-services on elopement and abuse neglect twice a week. They said they round on residents every 30 minutes. When residents exhibit exit-seeking, they are placed on 1-to-1 monitoring and the DON was informed. An assessment would then conducted and if they determine a wanderguard is needed resident's representative will sign the form and resident will be placed with one. Wanderguards are checked for function every shift. When asked what they would do if they can't find a resident, they said they would check that the resident didn't go out on pass or an appointment and check all the rooms. If resident can't be located, they will notify staff to assist. If they still cannot locate resident, they will tell the DON, Administrator and the resident's physician. Interview with CNA B on 2/28/24 at 1:30pm, she stated that she did not know the resident and did not work on his floor. When asked what she would do if a resident said they want to go home, she would check to see if they have any appointments. If not, she would redirect the resident and inform her Charge Nurse or DON of resident's behavior. If a resident cannot be located, she would search the building; if unsuccessful she would go to the nurse's station and call a Code Pink. If that is unsuccessful, someone would call the DON. CNA B had an in-service on abuse and neglect two weeks ago. She said they have elopement in-services and drills every few months. Interview with Staff A on 2/29/23 at 10:00am, they stated that CR #100 had cognitive impairment. They said he had orientation, memory, reasoning, and safety awareness deficits. Resident was verbal and never mentioned wanting to leave. Interview with Staff B on 2/29/23 at 10:10am, they stated that CR #100 was very cooperative. He was in rehab for endurance and strengthening so he could achieve his goal of living alone. Staff B was surprised and never thought the resident would leave and he never had any discussion or complaints about leaving facility. Interview with Staff C on 3/1/24 at 9:30am, she stated that she did not know the resident. She said if a resident was missing, she would look in all the rooms on her hall. If unsuccessful, she would call a Code Pink and have all staff search the building. If resident is still missing, someone will let the Administrator and DON know. Since resident eloped, she has not heard of another elopement that she's aware of. Interview with the facility receptionist on 3/1/24 at 9:16am, she stated that when she sees residents walking towards the door, she makes sure they have signed the on-pass binder (on-pass was when the resident has received permission to leave the facility) at the nurse's station. She said if residents leave with family they are expected to electronically check in, then go to the nurse's station to sign the on-pass binder before residents can leave. Observation on 3/1/24 at 11:45am, a sign near guest check-in stated that guests should sign 676356 Page 8 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0689 check-in binder at the nurse's station before leaving with residents. Level of Harm - Immediate jeopardy to resident health or safety Record review of facility's Elopement policy dated January 2023 revealed the guideline on facility response to being unable to locate a resident as follows: 1. Residents Affected - Few .immediately initiate a search of the entire community both inside and outside premises 2. Search all rooms within the community . 3. Conduct a complete head count of all residents . 4. If the resident is not located .notify the Administrator/DNS immediately 5. Confirm all doors and windows are secured. Check all door locking systems, door alarms .exit seeking alarm devices . Further review of the facility's Elopement policy stated that the facility is supposed to review sign out logs and confirm with family, notify the MD (resident's physician), Administrator/DON, medical director and initiate an investigation and implement and develop a 4-step response plan. Additional steps are to assess current residents for elopement and provide services such as wanderguards (which are bracelets that activate an alarm when residents get close to any exit doors) and/or placing residents on Memory Unit if needed, and to refer residents to psychiatric/psychological services. Record review of facility's Resident's Rights policy dated October 2022 states that resident rights include: all care necessary for them to have the highest possible level of health .to discharge themselves from the community unless they have been adjudicated mentally incompetent. Record review of the facility's Admissions Packet dated 10/12/2020 states that residents may leave the facility for therapeutic home visits called out-on-pass, with permission of resident's attending physician and RP (responsible party). Administration will be notified of all passes in advance and the resident will be signed in and out at the nurse's office. The The facility corrected the noncompliance by providing in-servicing and hands-on training regarding elopement for facility staff prior to state entrance, as evidenced below: Record review of facility's Discharge Assessment in-service acknowledgement dated 5/22/23 revealed charge nurses received training for how to discharge a resident in the online portal. Record review of the facility's daily staffing sheet for May 22, 2023, when CR #100 eloped from the 676356 Page 9 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility revealed that LVN C was working on resident's hall on day shift and RN B was working on resident's hall on night shift. Record review of facility's Residents leaving AMA in-service acknowledgement dated 5/23/23 revealed nursing staff receiving training on the process for when a resident requests AMA. The steps included: notify the doctor, notify the DON, notify the responsible party, have the resident fill out the release form, and writing a process note stating the resident choosing to leave AMA, the time they left and how they left. Record review of facility's Discharge and Residents Leaving Facility in-service acknowledgement dated 5/23/23 revealed nursing staff receiving education on documenting resident leaving the facility, including how the resident left and where the resident was in route to, and a note after resident return, if applicable. The signature page included RN B the nurse who marked Resident #1 as discharged without verifying physician orders. Record review of facility's Shift Change Rounds/Resident Count in-service acknowledgement dated 5/23/23 revealed nursing staff receiving education on being expected to perform room to room rounds during shift change and checking the census for their hall. Residents who are not accounted or not discharged from PCC (Point Click Care, electronic medical record system) are treated as a missing person/elopement and that the DON and Administrator must be notified immediately. The signature page included LVN A, the nurse who marked CR #100 as discharged without verifying physician orders. Record review of facility's Calling a Code: Elopement/Missing Resident in-service acknowledgement dated 5/24/23 revealed facility staff receiving education what to do when a resident is unaccounted for at a facility. Record review of facility's Code Pink Drill in-service acknowledgement dated 5/24/23 revealed nursing staff receiving education on what to do when a resident was missing or eloped. 676356 Page 10 of 21 676356 03/01/2024 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** Record review of Resident # 30's face sheet dated 02/29/24 revealed a [AGE] year-old female admitted to the facility on [DATE] re-admitted [DATE] with a diagnosis that included: [Dementia] a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory. Cerebrovascular disease ( stroke), paraplegia ( inability to voluntarily move the lower parts of the body), muscle wasting and atrophy, (aphasia) is a disorder that affects how you communicate [ Depressive disorder] is a mood disorder that causes a persistent feeling of sadness and loss of interest. Record review of Resident # 30's Quarterly MDS dated [DATE], revealed Resident #30 had a BIMS score of 01, which indicated severe cognitive Impairment. Resident #30 was indicated to always incontinent of bladder and bowel (inability of the body to control the evacuative functions of urination or defecation) and was dependent on assistance with her activities of daily living. Review of Resident # 30's care plan dated 01/09/2019, revealed a problem of Bladder Incontinence with interventions clean peri area with each incontinence episode. Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician. Observation on 02/29/24 at 9:32 AM. revealed that while providing incontinent care for Resident #30, CNA A using wet wipes. She did not open the labia to clean, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks with bowel movement, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #30. During an interview on 03/01/2024 at 3:25 PM CNA A revealed that she was nervous and forgot to open the labia to clean and cleaned the buttocks before applying the cleaned brief on Resident #30. CNA A said she had received incontinence care training within the last year, and she knew by not opening the labia to cleaned could cause urinary tract infection. Review of annual skills check for CNA A revealed CNA A passed competency for Perineal care/incontinent care on 07/18/2023. During an interview with the DON on 03/01/2024 at 3:25 PM., the DON stated that during the incontinent care of a female resident, Staff should wipe the peri area, then open the labia and clean downward. The DON said she was going to start incontinence care skills checks . The DON stated that if staff performed peri care deviating from policy, residents risked possible urinary infections. In an interview on 03/01/2024 at 3:35 PM, the Administrator stated his expectation was that incontinent care and hand washing were always done to prevent infection. Review of the facility's staff skills competencies on Perineal care (female Resident), dated 12/12/23, revealed: 676356 Page 11 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0690 Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . Level of Harm - Minimal harm or potential for actual harm For a female resident: Residents Affected - Some Wet washcloth and apply soap or skin cleansing agent. Wash perineal area, wiping from front to back. 1. Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) 2. Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. 3. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. 4. Gently dry perineum. Based on observation, interview, and record review the facility failed to ensure residents who are incontinent of urine received appropriate treatment and services to prevent urinary tract infection for 2 out of 7 residents (Resident #30 and Resident #66) reviewed for Foley catheter care. -LVN T failed to secure Resident #66 foley catheter tubing to prevent pulling on tubing . CNA A did not separate Resident #30's labia to clean during incontinent, clean around the buttocks and did not perform appropriate hand hygiene with glove changes throughout the care. This failure placed resident at risk for Foley catheter dislodgement, unwanted pain, and infections. Findings included: Record review of Resident #66's face sheet dated 07/03/2021 revealed an 76year old female admitted to the facility on [DATE] with the included diagnoses: dementia (a group of conditions characterized by my memory loss and judgement), acquired absence of left leg above the knee, peripheral disease (poor blood circulation), and retention of fluid (fluid buildup in the body tissues). Record review of Resident #66's MDS dated [DATE] revealed that resident had a BIMS score of 2 676356 Page 12 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0690 indicating that resident cognition was severely impaired. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #66's Physician orders revealed the following order: Residents Affected - Some -Dated 12/28/2023 Foley catheter 16 Fr dx: obstructive and reflux uropathy (when urine cannot drain through the urinary tract), check drainage each shift every day and night shift. Record review of Resident #66's care plan dated 02/02/2022 revealed that resident required an indwelling catheter 16 Fr/10 cc balloon with the following interventions: -Provide catheter secure band/tape as indicated. -Check tubing for kinks each shift and during each encounter. -Monitor for s/sx of discomfort and abnormalities report findings. Observation on 02/29/2024 at 11:42AM of staff CNA R and CNA S transferring Resident #66 from wheelchair to bed using a mechanical Hoyer lift. During transferred while staff was lifting resident out of the wheelchair with the mechanical Hoyer lift, resident began to complain of discomfort saying that she was experiencing pain in her vaginal area. The staff (CNA R and CNA S paused to see if resident Foley catheter tubing was pulling. At this time, it was observed that resident Foley catheter tubing was not secured to resident leg. The staff repositioned resident tubing to ensure that resident tubing was intact. When the staff transferred resident to her bed, further observation was made of resident bottom clothing with a wet spot. On the back of her pants. Further observation was made of resident brief soiled with pale yellow fluids and there was no urine observed in resident Foley catheter tubing or in Foley bag. CNA R and CNA S proceeded to provided resident Foley catheter care with no further concerns identified. Interview on 02/29/2024 at 12:10PM CNA R said she did not place resident in her wheelchair but another CNA did. CNA R said because Resident #66 had an indwelling Foley catheter, she should have had a stat loc on her leg to secure resident tubing to prevent the risk of the Foley catheter being pulled out. CNA R said it was the nurses that placed the stat locs on the residents to prevent the foley from being pulled out. CNA R said she would inform the nurse regarding resident Foley catheter tubing not draining properly as well as resident complaints of vaginal discomfort. Interview on 02/29/2024 at 12:15PM CNA S said she was just assisting CNA R with transferring Resident #66. CNA S said although she was a CNA and CMA , her role had changed to the staffing coordinator. Interview on 02/29/2024 at 12:20PM LVN T said after observing Resident #66's Foley catheter said she did not observe urine in resident tubing or bag, or a stat loc on resident leg to prevent Foley catheter being pulled out. LVN T said it was the nurses that were responsible for assessing the residents that had an indwelling Foley catheter ensuring that their Foley tubing was secured to leg. LVN T said she assessed Resident #66's Foley once a shift. LVN T said she did not recall assessing Resident #66 to see if her Foley catheter tubing was secured. After LVN T began to maneuver resident Foley tubing checking to see if the tube was in place, resident tubing began to flow with clear yellow fluids. Resident # 66 was no longer complaining of vaginal discomfort. LVN T went to get a stat loc to secure resident Foley tubing. 676356 Page 13 of 21 676356 03/01/2024 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 02/29/2024 at 1:00PM DON said it was the nurses that were responsible in assessing the residents with a Foley catheter to ensure that a stat loc was present to prevent the Foley catheter from being pulled out. The DON said the nurses should be assessing residents with Foley catheters at least once a shift and as needed. The DON was asked for the facility policy on Foley catheter. Record review of the facility policy on Incontinence and Catheterization revised January 2023 revealed in part: . Assessment and evaluation .Assessments also include consideration of the resident's overall condition, risk factors, and information about the resident's continence status, rationale for using a catheter, environmental factors related to continence programs, and the resident's responses to catheter/continence services . Resident #30 Bladder and Bowel Incontinence 676356 Page 14 of 21 676356 03/01/2024 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to provide pharmaceutical services that include procedures to ensure accurate acquiring, receiving, dispensing, administering of all drugs and disposingof expired medications for 2 of 4 medication carts residents (Nurse's cart for 100 and 200 hall) reviewed for medication storage. -The facility failed to ensure the nurse's cart for 100 hall,s did not have expired Lemon Glycerin swab sticks expired date 10/2023. -The facility failed to ensure the nurse's cart for 300 halls did not have expired lubricating jelly expired date 09/2023. These failures could place the residents in the facility at risk for not receiving needed medications to maintain optimum health, resulting in deterioration in their condition. Findings include: Observation on 02/28/24 at 4:48 p.m., of the nurse medication cart for 100 and 300 halls revealed the following: The medication listed below were in the original packet expired. -16 Lemon Glycerin swab sticks (Triple pack) expired date 10/2023. - 4 Sachet Lubricating jelly 3gm expired date 09/2023 Interview with LVN B on 02/28/24 at 4:48 PM, LVN B said she only worked as needed and she checked 100 hall medication cart whenever she worked. LVN B said she did not know the Lemon Glycerin swabs was expired until the surveyor A showed her. LVN B said she always checked the medication cart when she comes on duty for expired medication. Interview with RN A on 02/28/24 at 4:53 PM, RN A said she checked 300 hall medication cart whenever she works and lubricating jelly was only used for residents on as needed suppository. Interview with the DON on 02/29/24 at 3:00 PM, she said she just audited the medication carts and she missed those medications and lubricating jelly was not used. Interview with the DON on 03/01/2024 at 11:55 a.m. revealed whatever nurse was on shift and the medication aide checked the medication cart for expired medications. The DON said the nurse and medication aide monitored medications and the pharmacist comes to the facility once a month to document and checked for expired medications. The DON knew that giving residents expired medications could change chemical composition of the drugs over time which can render them unsafe or ineffective. Record review of facility policy on storage of medications, dated 2001 MED-PASS, Incorporated. (Revised April 2019) read . store all drugs and biologicals in a safe, secure and orderly manner .#5 .Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroy. 676356 Page 15 of 21 676356 03/01/2024 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 - Few 676356 Page 16 of 21 676356 03/01/2024 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 8% based on 2 errors out of 25 opportunities, which involved 2 of 5 residents (Resident #36, and #75) reviewed for medication errors. Residents Affected - Some 1.- MA B did not administer Turmeric capsule (a medication that helps the inflammation, metabolic syndrome, arthritis, hyperlipidemia, kidney) to Resident #75. 2.- LVN A poured (26mls) wrong dosage of Potassium Chloride 10mg/ml and was about to administered via GTube ( Gastrostomy tube) to Resident #36 . These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: 1. Record review of Resident #75's face sheet revealed a [AGE] year-old female admitted on [DATE] and was re-admitted on [DATE]. Her diagnosis included: hyperlipidemia (is an excess of lipids or fats in the body ), head of left femur fraction, (Alzheimer's disease) is a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks), age -related physical debility and unsteady gait. Record review of Resident #75's quarterly MDS assessment dated [DATE] revealed a staff assessment for mental status was conducted. BIMS score was 09.The resident's cognitive skills for daily decision making was moderately 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 #75's order summary report for 2/22/ 2024 revealed an order of Turmeric Curcumin Capsule 5-1000 mg ( black pepper -Tumeric) Give 3 capsule by mouth two times a day for supplement. Record review of Resident #75's medication administration record for February 2024 revealed Turmeric Curcumin Capsule 5-1000 mg 3 capsules (3000mg) was documented as administered on 02/27/22 at 8:35 AM by MA B. In an observation on 02/27/24 at 8:35 PM MA B prepared Resident #75's morning medications for administration. She prepared Turmeric Curcumin Capsule form 500 mg bottle ( 3 capsules (1500mg) was given to by mouth to Resident #75 with other medications). Instead of T Turmeric Curcumin Capsule 3000 mg being given. In an interview on 02/28/24 at 4:14 pm with DON regarding Turmeric Curcumin Capsule that MA A gave the wrong dose of 500 mg instead of 3000 mg. DON was shown the Turmeric Curcumin Capsule bottle 500 mg. DON said she was going to notify the doctor and she then ordered Turmeric Curcumin Capsule 1000 mg to correct the medication error. In an interview on 02/29/24 at 10:21 AM, the DON said nursing staff were trained to look at the 676356 Page 17 of 21 676356 03/01/2024 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 blister pack, bottles and match the eMAR (electronic medication administration record)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. In an interview with MA B on 03/01/2024 at 11:30 AM regarding Turmeric Curcumin Capsule 5-1000mg ( 500 mg 3capsules instead of 1000 mg 3 capsules to Resident #75), MA B said she was very sorry, and he had in-service from the DON and she had been working with the facility for over 5 years and she had training before on medication administration. She knew the 5 rights that included 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. 2. Record review of Resident #36's face sheet revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included: Gastrostomy status, ( G-Tube is a surgical procedure used to insert a tube, often referred to as a G-Tube for feeding), seizures ( sudden, uncontrolled electrical activity between brain cells( also called neurons or nerve cell causes temporary abnormalities in muscle tone or movements stiffness, twitching or limpness), cerebral infarction (stroke) and hemiplegia (paralysis of one side of the body. Record review of Resident #36's annual MDS assessment dated [DATE] revealed a BIMS score of 04 out of 15 which indicated severe cognitive impairment. She required extensive assistance of 2 staffs for bed mobility, dressing, and personal hygiene. She was totally dependent on 2 staffs for transfers and toilet use. Record review of Resident #36's care plan dated 02/18/24 revealed the resident had G-Tube. The intervention was to take diabetes medication as ordered by the doctor. Record review of Resident #36's order summary report for October 10, 2023, revealed an order for Potassium Chloride 20 milliequivalent (mEeq )/15millimiter(ml ) solution (10%) Give 20 mls via g-tube one time a day Record review of Resident #36's medication administration record for 2/2024 revealed Potassium Chloride 20meq/15mls solution (10%) Give 20 mls via g-tube one time a day was administered to Resident #36 by LVN A on 02/27/24 at the 8:55AM scheduled time. In an observation on 02/27/24 at 8:55 AM LVN A poured Potassium Chloride 26mls in a medication cup, LVN A checked Potassium Chloride solution and said it was 20 mls, and crushed other medications and was going to administer when the surveyor A called her attention and she wasted 6mls before administering through (via) g-tube. LVN A said she having problem reading the lines on the medication cups. LVN A said not giving medication as ordered was medication errors and she would be more careful. In an interview on 12/30/22 at 10:21 a.m. the DON said she expected staff to give Potassium Chloride 20meq/15ml solution (10%). Give 20 mls via g-tube one time a day as ordered by the physician 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 February 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 676356 Page 18 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0759 resident . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676356 Page 19 of 21 676356 03/01/2024 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 failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 2 residents (Resident #30) reviewed for infection control. Residents Affected - Few 1.CNA A failed to perform hand hygiene appropriately while providing incontinent care for Resident #30 by not changing gloves and washing hands . These failures could place residents at risk for transmission of diseases and organisms. The findings included: Record review of Resident # 30's face sheet dated 02/29/24 revealed a [AGE] year-old female admitted to the facility on [DATE] re-admitted [DATE] with a diagnosis that included: [Dementia] a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory. Cerebrovascular disease ( stroke), paraplegia ( inability to voluntarily move the lower parts of the body), muscle wasting and atrophy, (aphasia) is a disorder that affects how you communicate [ Depressive disorder] is a mood disorder that causes a persistent feeling of sadness and loss of interest. Record review of Resident # 30's Quarterly MDS dated [DATE], revealed Resident #30 had a BIMS score of 01, which indicated severe cognitive Impairment. The BIMS documented she had both long and short-term memory problems and could not recall the current season. She required extensive to total assistance of two or more staff for all ADLs. She was always incontinent of bowel and continent of bladder. Resident #30 was indicated to always incontinent of bladder and bowel and was dependent on assistance with her activities of daily living. Review of Resident # 30's care plan dated 01/09/2019, revealed a problem of Bladder Incontinence with interventions clean peri area with each incontinence episode. Goal: will remain clean, dry, and odor free with no occurrence of skin breakdown throughout the review date. Interventions: Monitor for incontinence every 2 hours or as needed, change promptly, and apply protective skin barrier; monitor for sign and symptom of skin break down and report abnormal findings to physician, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify physician. Observation on 02/29/24 at 9:32 AM. revealed that while providing incontinent care for Resident #30, CNA A using wet wipes. She did not open the labia to clean, did not change gloves, and repositioned the resident to her left side. Using wet wipes she cleaned in between the buttocks with bowel movement, did not clean around the buttocks then used the same gloves and picked up a clean brief put on the Resident #30. The resident was rolled to her back, and the brief was secured. CNA A pulled the blanket up to cover her legs. CNA A used the same gloves throughout while performing incontinent care, used the same gloves to open Resident #30's dresser and picked resident clean pants and top. During an interview on 03/01/2024 at 3:25 PM CNA A she said she was nervous and forgot to open the labia to clean and cleaned the buttocks before applying the cleaned brief on Resident #30. CNA A said she had received incontinence care training within the last year, and she knew by not opening the 676356 Page 20 of 21 676356 03/01/2024 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0880 labia to cleaned and not changing gloves could cause urinary tract infection. Level of Harm - Minimal harm or potential for actual harm In an interview with the DON on 02/29/24 at 3:53PM, she stated CNA A was one of the facility's lead aides that monitored other staff during orientation with for incontinent care. DON said not washing hands after changing gloves could cause urinary tract infections. DON said C.NA A knew she should clean around the buttocks before placing a clean brief. DON said she would be performing more in-services for incontinent care. Residents Affected - Few Review of the facility's policy titled; Handwashing/Hand Hygiene revised on 04/12/2019. Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 4. Single-use disposable gloves should be used: 1. before aseptic procedures; 2. when anticipating contact with blood or body fluids; and 3. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 676356 Page 21 of 21