Health inspection·March 22, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interview, and record review the facility failed to provide a comfortable and homelike environment for 2 of 8 residents (Resident #10 and Resident #16) whose environment was reviewed in that: Residents Affected - Few -The facility failed to properly store residents personal care item (toothbrush) to prevent cross contamination . This failure could place residents at risk for unwanted infections, and decrease in quality of life. Findings include: Observation on 03/20/2024 at 9:25 AM in Resident #10 and Resident #16's bathroom was a toothbrush sitting on the back of the commode lid with no name on the toothbrush. The toothbrush was not inside of a container. Interview on 03/20/2024 at 9:30 AM, RN S said she did not know who placed the toothbrush on the back of Resident #10 and Resident #16's commode lid. RN S said she did not know if the toothbrush belonged to Resident #10 or Resident #16. RN S said the toothbrush should be inside of a container and labeled to prevent cross contamination and infection control. Interview on 03/20/2024 at 9:50 AM, CNA V said she was the CNA for Resident #10 and Resident #16. CNA V said she was not aware of a toothbrush sitting on the back of the commode lid. CNA V said toothbrushes should be labeled and contained for infection control reasons. Attempted interview on 03/20/2204 at 9:55AM with Resident #10 and Resident #16 was unsuccessful. Interview on 03/20/2024 at 10:10 AM, the DON said when residents shared rooms all personal care items should be labeled and contained to avoid cross contamination. Record review of the facility's policy on Infection Control, revised October 2018, reflected in part: .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections ., Page 1 of 7 676454 676454 03/22/2024 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a residents' medical, nursing, and mental and psychosocial needs, that were identified in the comprehensive assessment for 1 of 5 residents (Resident #26) reviewed for care plans. The facility failed to develop a care plan to address Resident #26's for having a PICC line . This failure could place residents at risk for dislodgement, infections, and unwanted hospitalization. Findings include: Record review of Resident #26 face sheet, dated 03/21/2024 revealed a 74year old female admitted to the facility on [DATE]. Resident #26 diagnoses included osteomyelitis of vertebra (spine infection), type 2 diabetes mellitus (too much sugar in the blood), bacteremia (bacteria in the blood), heart failure and end stage renal disease. Record review of Resident #26 admission MDS, dated [DATE], reflected that the resident had a BIMS score of 11, which indicated that the resident's cognition was moderately impaired. Record review of Resident #26's Physician orders reflected the following order: -Dated 02/22/2024 IV Orders-Transparent dressing changes PICC one time a day every Sunday for line maintenance. Record review of Resident #26 care plan, dated 02/21/2024, reflected that the resident was not care planned for a PICC line. Observation on 03/21/2024 at 11:14 AM of Resident #26 revealed the resident was resting in bed with a PICC line to her upper right arm. Interview on 03/22/2024 at 10:30 AM with the DON, after reviewing Resident #26 care plan, said she would have to ask the MDS nurse why the resident was not being care planned for a PICC line . Interview on 03/22/2024 at 10:45 AM, the MDS nurse said it must have been an oversight on her part why Resident #26 was not care planned for a PICC line. The MDS nurse said the purpose for care planning Resident #26 for a PICC line was to identify any care issues, possible outcomes, monitor for signs and symptoms of complications, report to the physician if the resident PICC line was infiltrated (accumulation of excessive fluids in the tissue or cells), redness at site, or if the PICC line became dislodged. The MDS nurse said it was the DON that ultimately ensured that the care plans were being done accurately . 676454 Page 2 of 7 676454 03/22/2024 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0656 Record review of the facility's policy on Care Plans-Comprehensive, revised October 2010, reflected in part: Level of Harm - Minimal harm or potential for actual harm .The comprehensive care plan is based on thorough assessment and that includes, but is not limited to, the MDS, residents strengths and needs, personal and cultural preference, etc .Each resident's comprehensive care plan is designed to: identify problem areas and their causes, and developing interventions that are targeted and meaningful to the resident interdisciplinary processes that require careful data gathering .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans Residents Affected - Few 676454 Page 3 of 7 676454 03/22/2024 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 administer parenteral fluids consisitent with professional with professional standards of practice and care plans for 1 of 8 residents (Resident #26) reviewed for parenteral intravenous (IV) antibiotic care and services through a peripherally inserted catheter (PICC) therapy. Residents Affected - Some -The facility failed to change Resident #26's PICC line dressing once a week . -RN T failed to maintain sterile technique when changing Resident #26's PICC line dressing change . -The facility failed to date Resident #26's IV tubing. These failures could place residents at risk for infections, unwanted hospitalization, and decrease in quality of life. Findings include: Record review of Resident #26's face sheet, dated 03/21/2024, reflected a 74year old female admitted to the facility on [DATE]. Resident #26 had diagnoses which included osteomyelitis of vertebra (spine infection), type 2 diabetes mellitus (too much sugar in the blood), bacteremia (bacteria in the blood), heart failure, and end stage renal disease. Record review of Resident #26 admission MDS, dated [DATE], reflected the resident had a BIMS score of 11, indicating resident's cognition was moderately impaired. Record review of Resident #26's Physician orders reflected the following orders: -Dated 02/22/2024 IV Orders-Transparent dressing changes PICC one time a day every Sunday for line maintenance. -Dated 02/22/2024 Ceftriaxone intravenous solution use 1 gm intravenously one time a day for osteomyelitis of lumbar spine for 30 days end date 03/23/2024. Record review of Resident #26's TAR reflected that LVN W documented on 03/10/24 and 03/17/24 that Resident #26's PICC line dressing was changed. Record review of Resident #26's MAR reflected that the facility administered the antibiotic Ceftriaxone as ordered by the physician. Record review of Resident #26's Nursing Progress Notes reflected the dressing to the residents PICC line was changed on 03/03/2024. Observation on 03/21/2024 at 11:14 AM revealed Resident #26 had a PICC line to her right upper arm. The date on the dressing was 03/03/24. Further observation revealed an empty 50 ml IV bag connected to tubing that was not dated. Observation on 03/21/2024 at 12:11 PM revealed RN T changing Resident #26 PICC line dressing with 676454 Page 4 of 7 676454 03/22/2024 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the assistance of CNA U. RN T disinfected her workspace, washed hands, opened the sterile dressing kit. The kit had 2 surgical masks inside on top that RN T retrieved from the kit to place one on her and one on the resident. RN T began to don her sterile gloves. While donning sterile gloves, RN T tore one of the sterile gloves. RN T left the room to go and get another sterile dressing kit. RN T returned to the resident room and washed her hands. RN T proceeded by taking another set of sterile gloves out of the second sterile dressing and placed them on her hands. RN T with the sterile gloves began to place a drape dressing underneath the resident's right arm and proceeded to remove the old dressing from the resident's PICC line site. The site had crusted red brown debris but was without redness, swelling or drainage. When cleaning the site, RN T cleaned the site back and forward and not away from site. When RN T was done cleaning the site, she replaced the PICC line ports which were 2 (two) of them. When done with the PICC line dressing change, she placed all materials inside of a bag, and washed her hands. Interview on 03/21/2024 at 11:35 AM, RN T said the PICC line dressing was supposed to be changed once a week to prevent the PICC line from getting infected . Interview on 03/21/2024 at 2:35 PM, the DON said the nurses were supposed to change the resident's PICC line dressing every Sunday on the night shift for maintenance of the PICC line and to prevent the line from getting infected. The DON said LVN W no longer worked at the facility. Interview on 03/21/2024 at 11:35 AM, RN T said the PICC line dressings were supposed to be changed once a week and IV tubing should be labeled for infection control reasons. RN T said IV tubing was supposed to be changed every 24-hours . Interview on 03/21/2024 at 11:57 AM, the Wound Care Nurse said it was the nurses on the unit who changed the PICC line dressings. Interview on 03/22/2024 at 10:30 AM, the DON said RN T was off work but she had spoken to RN T who told her she broke the sterile field when she was changing Resident #26's PICC line dressing on 03/21/2024. The DON said she had all the nurses take the IV-line certification class. Attempted interview on 03/22/2024 at 10:55AM via phone with RN T regarding PICC line dressing change, no answer, left message. Record review of training reflected that RN T had completed Parenteral Nutrition Training dated 08/24/2023. Record review of the facility's policy on Central Venous Catheter Dressing Changes, revised April 2016, reflected in part: .The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings .To remove dressing non-sterile gloves .To replace sterile dressing sterile central venous catheter dressing change kit .Open sterile dressing kit, apply mask .Apply sterile gloves. Once the gloves are on, only the contents of the kit can be touched 676454 Page 5 of 7 676454 03/22/2024 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

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 and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure expired foods were not discarded 2. The facility failed to ensure foods were labeled and dated. These failures could place residents at risk of food borne illness and disease. who ate food from the kitchen and place them at risk of food borne illness and disease. Findings Included: Observation of the facility kitchen on 03/19/24 at 8:10 AM revealed the following leftover foods were not discarded prior to the use by date. 1. A Plastic Container of American Cheese was dated 3/07/24. 2. A Plastic Container of Cubed Cheese had no label and was not dated. 3. A Plastic Container of Cubed Cheese was dated 2/23/24 4. A Plastic Container of Sliced Deli Ham was dated 3/11/24 5. A Plastic Container of Butterscotch Pudding was dated 3/12/24 6. A Plastic Container of Banana Pudding was dated 3/14/24 7. Two Plastic Containers of Pimento Cheese had an expiry date 3/14/24 Interview with the Dietary Food Service Manager on 03/19/24 at 8:25 AM she stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date. Record review of facility's policies and procedures for Handling Leftover Food dated 2020 read in part .4. Leftover foods stored in the refrigerator shall be wrapped, dated, labeled with a use by date that is no more than 72 hours, from the time of first use. 5. Refrigerated leftovers stored beyond 72 hours shall be discarded. Food Code Reference 483.60(1) (1) (812). 676454 Page 6 of 7 676454 03/22/2024 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Residents Affected - Some Food and Nutrition Services. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings included: Observation on 03-19-24 at 8:30 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and the door was wide open. The dumpster was in proximity to the door from the kitchen to the area. In an interview on 03-19-24 at 8:35 am, with the Food Service Manager , she stated the dumpster doors always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. Record review of facility's Nutrition Policies and Procedures on waste disposal dated 2020 read in part . 8. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. 676454 Page 7 of 7