Health inspection·June 27, 2025

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 interview, and record review the facility failed to have an established system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and failed to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 (CR #1) of 5 residents reviewed for pharmacy services. The facility failed to document CR #1's ABH cream on her May 2025 MAR. The facility failed to document CR #1's Morphine on her April 2025 MAR. The facility failed to document CR #1's Morphine on her May 2025 MAR. These failures could place residents at risk for inaccurate administration of medication, over medication, or drug diversion. Findings include: Record review of #CR 1's undated face sheet reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses of senile degeneration of brain (also known as dementia: progressive decline in cognitive function, impacting memory, reasoning, and daily tasks), type 2 diabetes mellitus (body does not make insulin or resists it), Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia with psychotic disturbance (dementia with seeing/hearing/believing things that are not real), generalized anxiety disorder, adjustment disorder with anxiety and depressed mood (anxiety and depressive symptoms in response to a stressor), insomnia (unable to sleep), polyneuropathy (nerve pain), palliative care (hospice), and hypertension (high blood pressure). Record review of #CR 1's Quarterly MDS Assessment, dated 4/29/25, reflected she had a BIMs score of 2 out of 15, which indicated severely impaired cognition. The MDS also revealed she had fluctuating inattention and disorganized thinking (lack of coherence, clarity, and logic). She was substantial/max assistance (helper does more than half the effort) with all of her ADLs. CR #1 was frequently Page 1 of 9 676356 676356 06/27/2025 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 incontinent of bowel and bladder. The MDS revealed CR #1 was on an antipsychotic (medications to manage psychosis and other psychotic disorders), antianxiety, opioid, and an anticonvulsant, and she was on hospice. Record review of #CR 1's Comprehensive Care Plan, dated 1/24/25 revealed a Focus: Admit to facility with Hospice for dx: senile degeneration of the brain (Initiated: 1/27/25). The goal was to have comfort, quality of life and dignity protected and honored. The interventions included administering medications/treatments as recommended by the doctor, coordinating care with the hospice team, and having the hospice nurse coming to visit. Focus: CR #1 required anti-anxiety medication r/t senile degeneration of brain and h/o anxiety/agitation (Initiated: 1/24/25, Revised: 6/24/25). The goal was to have no complications r/t anti-anxiety meds through review date. The interventions included multiple GDRs, administering meds as ordered, family education, and monitoring side effects. Focus: CR #1 required psychotropic (medications that affect mental state) medications (Initiated: 1/24/25, Revised: 6/24/25). The goal was to experience less than daily behavioral episodes of targeted behaviors. Interventions included administering ordered medications, diverting attention, and educating family on behaviors. Focus: CR #1 was at risk for pain r/t senile degeneration of brain (Initiated: 1/24/25, Revised: 6/24/25). The goal was to maintain a tolerable comfort level through the review date. Interventions included administering medications to relieve pain. Record review of #CR 1's Physician's Orders revealed the following orders from MD G: Morphine Sulfate Oral Solution 20mg/5ml, Give 2.5ml PO Q4hr PRN pain, SOB. Ordered on 3/18/25. ABH 1mg/25mg/1mg/1ml mg/ml (Ativan [treats anxiety] 1mg, Benadryl [helps with sleep] 25mg, Haldol [helps with hallucinations] 1mg) Apply to inner wrist topically at bedtime r/t dementia with psychotic disturbance. Ordered on 5/7/25. ABH 1mg/25mg/1mg/1ml mg/ml (Ativan 1mg, Benadryl 25mg, Haldol 1mg) Apply to inner wrist topically Q4hr PRN for anxiety. Ordered on 5/7/25. Record review of CR #1's April 2025 MAR revealed the following days/times of Morphine administration documentation: 4/2/25 at 10:26am 676356 Page 2 of 9 676356 06/27/2025 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 4/4/25 at 2:15am Level of Harm - Minimal harm or potential for actual harm 4/19/25 at 9:34am Residents Affected - Some Record review of CR #1's April 2025 Morphine Controlled Drug Receipt/Disposition Form revealed the following missing dates/times of administration: 4/3/25 at 12:00pm 4/12/25 at 3:00pm 4/13/25 at 10:00am Record review of CR #1's May 2025 MAR revealed no documentation of Morphine administration. Record review of CR #1's May 2025 Morphine Controlled Drug Receipt/Disposition Form revealed the following missing dates/times of administration: 5/28/25 at 11:30am 5/28/25 at 3:30pm 5/28/25 at 11:30am Record review of CR #1's May 2025 MAR revealed the following dates/times of ABH cream administration: 5/1/25 at 10:25pm 5/2/25 at 6:31pm 676356 Page 3 of 9 676356 06/27/2025 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 - Level of Harm - Minimal harm or potential for actual harm 5/3/25 at 8:35pm - Residents Affected - Some 5/4/25 at 12:37am 5/4/25 at 7:38am 5/4/25 at 3:37pm 5/5/25 at 9:38am 5/5/25 at 10:03pm 5/6/25 at 8:58am 5/6/25 at 7:42pm 5/7/25 at 8:13pm 5/8/25 at 8:28am 5/9/25 at 12:08am 5/10/25 at 7:40pm 676356 Page 4 of 9 676356 06/27/2025 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 5/11/25 at 7:10pm Level of Harm - Minimal harm or potential for actual harm 5/12/25 at 8:16pm Residents Affected - Some 5/13/25 at 3:52pm 5/15/25 at 7:10am 5/15/25 at 7:29pm 5/16/25 at 9:24pm 5/16/25 at 11:29pm 5/17/25 at 10:44pm 5/18/25 at 9:49pm 5/19/25 at 1:00pm 5/19/25 at 9:13pm 5/20/25 at 2:56pm 5/20/25 at 9:23pm 676356 Page 5 of 9 676356 06/27/2025 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 - Level of Harm - Minimal harm or potential for actual harm 5/21/25 at 10:13am - Residents Affected - Some 5/21/25 at 7:18pm 5/22/25 at 11:00am 5/22/25 at 8:12pm 5/23/25 at 8:01pm 5/24/25 at 8:10pm 5/25/25 at 9:10am 5/25/25 at 7:22pm 5/26/25 at 10:13am 5/26/25 at 7:34pm 5/27/25 at 10:37am 5/27/25 at 8:02pm 676356 Page 6 of 9 676356 06/27/2025 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 5/29/25 at 2:36am Level of Harm - Minimal harm or potential for actual harm 5/29/25 at 7:06pm Residents Affected - Some 5/30/25 at 7:12pm 5/31/25 at 8:59pm Record review of CR #1's May 2025 ABH Controlled Drug Receipt/Disposition Form revealed the following missing dates/times of administration: 5/7/25 8:30am 5/10/25 8:00pm 5/12/25 7:00am 5/14/25 11:00pm 5/24/25 3:00am 5/25/25 1:00pm 5/28/25 8:00am 5/28/25 2:00pm 676356 Page 7 of 9 676356 06/27/2025 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 - Level of Harm - Minimal harm or potential for actual harm 5/28/25 8:00pm CR #1 passed away on 6/24/25, and was unable to confirm receipt of medication. Residents Affected - Some In an interview with the DON on 6/26/25 at 1:30pm, she said the staff members probably forgot to check off the medication on the MAR but gave the medication to CR #1. She said she was starting in-services on filling out the MAR and accurate documentation on the Controlled Substance Log. In an interview with LVN R on 6/26/25 at 1:50pm regarding the missing entries on the Controlled Drug Log for CR #1, she said she did not remember what happened, but she was pretty sure she gave the medication and forgot to document it on the MAR. Attempted to interview LVN S on 6/26/25 at 3:35pm but was unsuccessful. His mailbox was full, and a message could not be left. In an interview with the DON on 6/27/25 at 10:30am, she said she stayed late on 6/26/25 and audited all of the Controlled Substance Logs with resident's MARs to ensure accuracy. She said she also performed in-services with all staff on the importance of accurate documentation. She said there was not a procedure in place to check the Controlled Drug Log against the resident's MAR, but she did QAPI it and now the logs would be checked 2-3 times a week. She said if the Controlled Drug Log did not match the resident's MAR, it could indicate a drug diversion. In an interview with RN D on 6/27/25 at 12:55pm, she said she remembered she gave the first dose of ABH on 5/25/25 at 9:00am to CR #1 and it did not work so she had to go back later and give another dose around lunch time after CR #1 slapped a CNA in the face. She said it was crazy trying to get CR #1 to calm down and she must have forgotten to check the medication off on the MAR. In a telephone interview with LVN A on 6/27/25 at 1:12pm regarding missing entries on the MAR for CR #1, she said she must have forgotten to check them off. She said she was usually pretty good about her controlled medication documentation but sometimes CR #1 was hard to handle, and she would have to hurry and give her medications, and she must have forgotten to chart it. In a telephone interview with LVN R on 6/27/25 at 2:04pm regarding missing entries of Morphine on CR #1's MAR, she said she was pretty sure she wasted the Morphine at 11:30am on 5/28/25 and that was why there were 2 entries for 11:30am. She said she was pretty sure she gave it at 3:30pm. Record review of the facility's policy and procedure on Controlled Drugs (Revised January 2023) read in part: To provide guidance on the process where Controlled Drugs are inventoried and administered as required by state and federal agencies. When administering a controlled medication, identify the medication in the resident eMAR, review the control sheet and indicate the remaining accordingly. Administer the medication and sign the eMAR and control sheet accordingly. The eMAR should not be signed until after the medication administration. Record the results of medications administered as necessary. Maintain a declining inventory record per resident per drug on all Controlled drugs. Records should be accurate and include: Name of the resident .Date and time of administration .If a medication was missed, not administered, was not refused the nurse should complete a medication error report. Admin/DNS/Designee will notify local and state [agencies] if appropriate . 676356 Page 8 of 9 676356 06/27/2025 The Heights of North Houston 303 Hollow Tree Lane Houston, TX 77090

F 0755 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy and procedure on Medication Administration (Revised January 2023) read in part: Resident medications are administered in an accurate, safe, timely, and sanitary manner .Initial the electronic administration record after the medication is administered to the resident. Residents Affected - Some 676356 Page 9 of 9