Health inspection·December 7, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for in 1 of 5 residents (Resident #35) reviewed for catheters . 1. The facility failed to secure Resident #35's urinary catheter and tubing. 2. -The facility failed to ensure CNA A properly cleaned Resident #35 during incontinent care. These failures could place residents at risk for urinary tract infections (UTI) , urethral erosions, discomfort, skin breakdown, and a decreased quality of life. Findings included: Record review of Resident #35's face sheet, dated 12/07/2023, reflected, an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included: essential (primary) hypertension (high blood pressure) and end stage renal, Foley catheter ( soft, plastic or rubber tube that is inserted into the bladder to drain the urine). Record review of Resident's #35 admission MDS assessment, dated 11/27/2023, reflected the resident had a BIMS score of 00, which reflected the resident's cognition was severely impaired. Resident # 35 had an indwelling catheter. Record review of Resident's #35's care plan, dated 11/27/2023, reflected Resident #35 had an indwelling catheter. Staff was were to ensure tubing was secured to the resident's leg so ttubing was not pulling on the urethra. Monitor for leg strap placement and change as needed. Record review of Resident #35's Physician's order, dated 11/24/23, reflected Check Foley privacy bag and leg strap every shift. Record review of Resident #35's MAR/TAR flowsheet, dated 12/1/2023, reflected initials documented for Check Foley privacy bag and leg strap every shift, which indicated it was done. During an observation on 12/07/2023 at 11:34 AM revealed C.NA A entered Resident #35's room, without washing hands, donned clean gloves and emptied 200 from Resident #35's Foley catheter drainage bag in the urinal. CNA A, then took the urinal and poured the contents in the resident's commode. The Foley catheter was not secured. Page 1 of 8 676381 676381 12/07/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/07/2023 at 12:03 PM with CNA A revealed Resident #35 did not have any strap to secure the Foley catheter, hence it was allowing the Foley tubing to move freely and she was not responsible for securing the catheter the nurse were responsible for securing the strap and she forgot to watch her hands or use hand sanitizer after changing her gloves. Interview with the DON on 12/07/2023 at 3:35 PM, the DON said she would in-service the staff and his expectation was to avoid injury to any resident with an indwelling catheter and the charge nurses were to check. Interview with the charge nurse on 12/07/2023 at 4:57 PM, the charge nurse said she changed the leg strap for Resident #35, 2 days ago. She stated Resident #35 had a leg strap in place and she checked it the morning on 12/07/23, the leg strap was there. She stated the purpose of the strap was to secure the Foley to prevent injury. The charge nurses were supposed to check daily to ensure the leg strap was in place and the C.NA's were to report to the nurse if the strap was not in place. Record review of the facility's Catheter Care, urinary policy, printed on 12/06/2023, did not reflect how to secure the indwelling Foley catheter and no relevant policy was provided before exit on 12/07/23 . 676381 Page 2 of 8 676381 12/07/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

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. **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 assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals,) to meet the needs of each resident, for 1 of 4 residents (Resident # 12) reviewed for :pharmaceutical services. MA A administered Resident #12 Pregabalin capsules and extended -release almost 2 hours after the scheduled timeframe. (Pregabalin is a long -acting a medication used to relieve neuropathic pain) pain from damaged nerves that can occur in your arms, hands, fingers, legs, feet or toes if you have diabetes and certain types of seizures ( Focal seizures=a sudden uncontrolled burst of electrical activity in the brain). This deficient practice could place residents at risk for not receiving a therapeutic effect. The findings were: Record review of Resident #12's face sheet, dated 12/06/23, reflected Resident #12 was [AGE] years old female admitted to the facility on [DATE]. Resident #12 had diagnoses which included chronic pain, conversion disorder with seizures or convulsions ( a condition where brain cells malfunction and send electrical signals uncontrollably), gastro-esophageal reflux disease without esophagitis ( stomach acid travels upward into esophagus), adjustment disorder with mixed anxiety and depressed mood, generalized anxiety disorder, insomnia due to medical condition (,lack of sleep) and muscle weakness. Record review of Resident's #35 admission MDS ( Minimum Data Set) assessment, dated 11/27/2023, reflected a BIMS score of 15, which reflected the resident's cognition was not impaired. Record review of Resident #12's physician orders, obtained, 12/01/2023, reflected the following orders: - Pregabalin capsule 75 mg by mouth three times a day related to other Seizures (7AM, 2PM 7 PM). The start date of this medication was 03/30/23. Record review of Resident #12's December 2023 MAR and TAR , obtained 12/01/23, reflected Resident #12's Pregabalin capsule 75 mg by mouth three times a day related to other seizures was scheduled to be given at (7AM, 2PM 7 PM) Observation on 12/01/23 at 9:42 AM. revealed MA A began to prepare Resident #12's Pregabalin capsule 75 mg, MA A placed Resident #12's Pregabalin capsule 75 mg and other medications into a plastic medication cup and gave by mouth. During an interview on 12/07/23 at 4:37 PM., MA A, MA A stated the training she had to ensure the resident took medications at the right time were the rights of medication administration which included the right resident, right dose, right documentation, right route, and right time. MA A stated medication should be given an hour before or an hour after the scheduled time. MA A stated it was 676381 Page 3 of 8 676381 12/07/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0755 important to ensure the right time for Resident #12's medication., because it could harm the resident . Level of Harm - Minimal harm or potential for actual harm During an interview on 12/07/23 at 5:10 p.m., the DON stated, we have the [medication administration] competency that's done upon hire and we do it annually as a refresher and we also do it as needed. Corporate will come in and they'll do an observation, and they'll make recommendation. It's a lot of [as needed] from time to time. The DON stated the facility's consulting pharmacist will also visit to do cart audits and medication administration observations. The DON stated the facility also conducted random medication cart checks weekly and these audits included checking if medication was given at the right time. The DON stated their medication administration time was from 6:00 AM to 11:00 AM for morning medication except a scheduled time should be given 1 hour before and 1 hour and hour after. , The DON stated, Depending on the medication, itself, it can have an effect where it's running into another medication that it shouldn't be given near and if you're not going an appropriate amount of time you can give something too close together. You can get sedations, you can get all sorts of outcomes by not following when the medication is supposed to be given. Residents Affected - Few Record review of a the facility policy titled, Administering Medications, dated 05/2023, did not address the following: Medications are administered in accordance with the prescriber orders, including any required time frame . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. 676381 Page 4 of 8 676381 12/07/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 Medication Carts and one medication room reviewed for medication storage. 1. The facility failed to ensure the Medication room cabinet did not have 3 bottles of expired vitamin ( B-6) stored . 2. The facility failed to ensure the 300 hall medication cart did not have eye drops and vaginal creams were dated with open dates. 3. The facility failed to ensure the 100 and 400 hall had 5 eyes drops were dated with no open dates . These failures could place residents at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident, which could lead to exacerbation of their disease process and deterioration in general health. Findings include: During observation and interview on 12/06/23 at 3:16 PM of the Medication Cart for 300 Hall with LVN C, observationrevealed in the there were 2 Artificial tears eye drops ( 1/2 Fl. oz (15), 1 Ciprofloxacin ophthalmic solution USP 0.3%,. 1 Estradiol cream 0.01% (Vaginal Cream), 1 Triamcinolone Acetonide Cream 0.1% 80 gram and 1 Ammonium Lactate Cream 12% that did not document an open date. LVN C stated staff should always write an open date on medications and she was not sure who opened the medications. LVN C stated placing an open date would help to know when the medication expired. During observation and interview beginning on 12/06/23 at 3:49 PM of the Medication room with LVN A and the DON revealed three Vitamin B-6 ( Dietary supplement) bottles of 100 tablets each documented a best by date of 3/2023. LVN said she checked the expired med room daily. The DON said she checked medication rooms daily and she just checked the medication room that morning and the pharmacy also checked with her . During observation and /interview on 12/06/23 at 4:20 PM, of Medication Cart for 100 and 400 Hall with MA B, revealed of in the drawer was 1 Simbrinza suspension 1- 0.2% , 1Timolol Mal [NAME] 0.5% , 1 Latanoprost ophthalmic solution 0. 005%, 1 Aphagan P. solution 0.1%. and 1 Dorzolamide did not have open dates documented. MA B said when eye drops or ointment were opened, it should be dated to help know when it should not be used . Interview on 12/06/23 at 6:00 PM with the DON Revealed a negative outcome for a resident who received eye drops or creams that were not dated was it could make them sick and the medication. may not 676381 Page 5 of 8 676381 12/07/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0761 work so good . Level of Harm - Minimal harm or potential for actual harm Interview on 12/07/23 at 4:59 PM with the DON revealed the facility had no policy on expiration labeling of medications. Residents Affected - Some Record review of the facility's Medication Storage policy, printed on 12/06/2023, dated 05/2023, did not reflect how to secure the medication storage 676381 Page 6 of 8 676381 12/07/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #35 and #94) reviewed for infection control practices. Residents Affected - Some 1. CNA A did not utilize appropriate hand hygiene during Foley catheter care for Resident #35 2. CNA A did not utilize appropriate hand hygiene during incontinent for Resident #94 These failures could place residents at risk of infection or a decline in health. The findings include: Record review of Resident #35's face sheet, dated 12/07/2023, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included: essential (primary) hypertension (high blood pressure) and end stage renal, Foley catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine). Record review of Resident's #35 admission MDS assessment, dated 11/27/2023, reflected the BIMS score was 00, which indicated the resident's cognition was severely impaired.Resident # 35 had an indwelling catheter. During an observation on 12/07/2023 at 11:34 AM revealed indwelling catheter care for Resident #35's. CNA A entered Resident #35's room,did not wash hands and donned cleaned glove. CNA A emptied 200 from the Foley catheter drainage bag in the urinal, then took the urinal and poured the contents in resident's commode. During an observation on 12/07/2023 at 11:36 AM revealed CNA A used the same gloves, to picked up wet wipes from Resident #35's drawer. CNA A undid the resident's brief and used the wet wipes to clean the penis head twice. CNA A did clean Foley Catheter tubing, she then fasten the brief. CNA A used the same gloves to adjust Resident #35's bed linen CNA then removed soiled pillowcase in a plastic linen bag, she removed soiled gloves without washing her hands, opened Resident #35's main door to the clean linen room and picked up a cleaned pillow case. CNA A donned clean gloves and placed a pillowcase under the resident's head. CNA A removed gloves and did not wash hands and went to Resident # 49's room and made the bed. CNA A went to Resident #94's room to perform incontinent care and did not wash her hands. CNA A put clean gloves on. 2. Record review of Resident #94's's face sheet, printed on 12/07/2023 at 2:00 PM, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #94 had diagnoses which included: respiratory failure, hemiplegia (weakness of the left side of the body), muscles weakness and lack of coordination. Record review of Resident #94's admission MDS, dated [DATE], reflected she had both short term and long-term memory problems. She had severely impaired cognitive skills for daily decision making. She required extensive assistance of one or two-person physical assist for toilet use, bed mobility, dressing and personal hygiene. She was always incontinent of urine and bowel. 676381 Page 7 of 8 676381 12/07/2023 West Houston Rehabilitation and Healthcare Center 13428 Bissonnet Houston, TX 77083

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #94's comprehensive care plan, revision date 11/30/23, reflected the resident was at risk of urinary tract infections. Interventions included for caregiver teaching to include good hygiene practices, wipe, and cleanse from front to back and clean peri area well after bowel movement in order to help prevent bacteria in urinary tract. Observation on 12/07/23 at 11:49 PM during incontinent/peri care revealed CNA A put on clean gloves without washing hands. CNA A picked up a clean brief and wipes from Resident #94's dresser and placed it on the bed. CNA A repositioned the resident to her left side, opened the soiled brief which had fecal matter. CNA A used the wet wipes, cleaned the rectal area with wipes several times, she did not remove her gloves and did not utilize appropriate hand hygiene. CNA A removed the soiled brief and placed the clean brief on the resident. CNA A put on a new pair of gloves and completed incontinent/peri care. During incontinent/peri careCNA A took a face towel and wet it in water and cleaned Resident #94's groin and labia and fasten the brief. Then covered the resident with her linen and blanket. During an interview on 12/07/23 at 12:02 PM, CNA A revealed she was supposed to utilize appropriate hand hygiene, such as using hand sanitizer, between glove changes when providing incontinent/peri care to Resident #94 because it was considered cross contamination. She stated this could cause the resident to develop an infection such as a urinary tract infection. CNA A said she had received training on utilizing appropriate hand hygiene by the DON. During an interview on 12/07/23 at 3:25 PM, the DON revealed staff should be utilizing appropriate hand hygiene practices to prevent an infection. The DON revealed it was necessary to sanitize or wash the hands between glove changes. The DON stated she would conduct in-services now on peri care and infection control. Record review of the competency training titled, Personal Protective Equipment (PPE) Competency Validation, dated 8/8/23, reflected CNA A had satisfied the requirements for hand washing and effective use of PPE. The competency training reflected in part, .Don gloves: Extend to cover wrist .Remove gloves: Grasp outside of glove with opposite gloved hand; peel off .perform hand hygiene Record review of the facility's Incontinent Care policy, printed on 12/06/2023, dated 02/2023,did not reflect hand hygiene. 676381 Page 8 of 8