Health inspection·June 18, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all patient care equipment was in safe operating condition for one (Resident #1) of five residents reviewed for safe operating patient care equipment. The facility failed to ensure Resident #1 had a functioning toilet. This failure could place residents at risk of unsanitary conditions. Findings included: Record review of Resident #1's face sheet dated 6/18/25 revealed a [AGE] year-old male who admitted to the facility on [DATE]. His diagnosis included age-related cognitive decline, cellulitis (bacterial infection of the skin) of left lower limb, pain disorder, and cerebral infarction (stroke). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. He was always continent of bowel and bladder and required assistance from staff with toileting hygiene and toilet transfers. Record review of Resident #1's care plan edited 5/23/25 indicated he required assistance with ADL's, the approach included toileting with assist of independent. His care plan also indicated he had periods of socially inappropriate and verbal aggression. Resident #1 had a preference of using bags and bed pans to defecate and urinate in rather than use the toilet, dated 6/17/25. In an interview and observation on 6/17/25 at 9:21 a.m. in Resident #1's room revealed the sound of running water coming from the toilet. The toilet was not in use. The Surveyor attempted to flush the toilet and it would not flush. Resident #1 said his toilet had not been working since March (2025). He said he used a urinal and a bed pan and had to dispose of his urine and feces in his trash can because his toilet did not work. He said he did not want the staff to dispose of the urine and feces in his shower or sink. He said he informed the Receptionist and Maintenance Director that his toilet was not working (unknown date). In a telephone interview on 6/17/25 at 11:19 a.m. Resident #1's family member said the resident's toilet did not work and staff complained because he used his trash can for his bodily waste. In an observation and interview on 6/17/25 at 1:06 p.m. revealed CNA R attempted to flush Resident #1's toilet and it would not flush. She said the resident used the toilet this morning and it was Page 1 of 2 676463 676463 06/18/2025 Crimson Heights Health & Wellness 19279 McKay Dr. Humble, TX 77338

F 0584 Level of Harm - Minimal harm or potential for actual harm working. She said Resident #1 used a bedpan and urinal and she would empty his urine in his toilet. She said she would report the non-working toilet. In an interview on 6/17/25 at 2:37 p.m. the Administration Assistant said Resident #1 informed her he had concerns with the toilet in his bathroom on an unknown date. Residents Affected - Some In an interview on 6/17/25 at 4:52 p.m. the Maintenance Director said he was not aware that Resident #1's toilet was not flushing. He said the Assistant Maintenance primarily repaired toilets. In an observation and interview on 6/17/25 at 5:18 p.m. the Assistant Maintenance attempted to flush Resident #1's toilet but it would not flush. He said no one informed him that Resident #1's toilet was not working. He said to his knowledge the toilet was flushing previously and the aide said the resident did not use the toilet. He said he would have to notify the Maintenance Director about the toilet. In an interview on 6/17/25 at 5:25 p.m. CNA L said she was unsure if Resident #1's toilet was flushing properly. She said sometimes it flushed properly but other times the water would go down slowly. She said Resident #1 disposed of his waste in his trash can. In an interview on 6/17/25 at 5:40 p.m. the Administrator said he expected residents' toilets to function properly and for the Maintenance Director to address any problems. He said Resident #1's toilet not working was new and was not on the maintenance log. Record review of the facility's Maintenance Log for June 2025 revealed Resident #1's toilet was flushing slowly on 6/17 and was resolved on 6/17. Record review of the facility's Maintenance/Housekeeping - Routine Maintenance policy dated 3/2006 reflected in part, . the center performs routine maintenance on floors, walls, fixtures and equipment . Record review of the facility's Maintenance/Housekeeping - patient/resident room checklist policies and procedures dated 7/26/2017 reflected in part, . toilet . flush toilet to ensure adequate flow . 676463 Page 2 of 2