The Heights Of Tomball

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to transmit an MDS for 2 (Resident #57 and Resident #112) of 3 residents reviewed for resident assessment. The facility failed to transmit End of PPS Part A stay 12/13/2023 for Resident #57. The facility failed to transmit End of PPS Part A stay 11/10/2023 for Resident #112. The facility failed to transmit Discharge Return Not Anticipated 12/13/2023 for Resident #57. The facility failed to transmit Discharge Return Not Anticipated 11/10/2023 for Resident 112. This failure could place the residents at risk of not having their assessments transmitted timely. Findings include: Record review of Resident #57's admission record revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: Encephalopathy (a group of conditions that cause brain dysfunction), fracture of right wrist and hand, and urinary tract infection. Resident was admitted for skilled nursing following hospitalization. Resident discharged from the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident rooms was adequately equipped at the resident's bedside to call for staff assistance through the communication system for 1 of 3 sampled residents (Resident #6) reviewed for call light function, in that: -The facility failed to ensure Resident #6 bedside call light was functioning. Findings included: Record review of Resident #6's face sheet, dated 03/28/2024, revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with hemiplegia (one-sided paralysis of the body) , anxiety disorder, dementia, and cerebral infarction (disrupted blood flow to the brain). Record review of Resident #6's MDS, dated [DATE], revealed the resident needed supervision to touching assistance for toileting showering, dressing and personal hygiene. Record review of Resident #6's care plan, not dated, reflected a focus noting resident had a self-care deficit related to diagnosis including weakness, debility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 3 residents (Resident #1) reviewed for professional standards. -The facility failed to obtain PICC care and dressing change orders for Resident #1 after completion of antibiotics on 08/25/2023 resulting in Resident #1 receiving no dressing change and no catheter flushes between 08/25/2023 and 08/29/2023. These failures could place residents at risk of infection, pain, and hospitalization. Findings included: Record review of Resident #1's Face Sheet dated 08/29/2023 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include cellulitis (skin infection) of the left lower limb, diabetic peripheral angiopathy (disease of the blood vessels as a result of unregulated diabetes), proteus mirabilis (microorganism causing infection), heart disease, local infection of the skin and peripheral vascular disease (a blood circulation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice and care plans for 1 of 3 residents (Resident #1) reviewed for parenteral IV antibiotic care and services through a PICC therapy. - The facility failed to provide care or dressing changes to Resident #1's IV catheter site from 08/19/2023 to 08/29/2023. This failure could place residents at risk for infection, pain, and hospitalization. Findings included: Record review of Resident #1's Face Sheet dated 08/29/2023 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include cellulitis (skin infection) of the left lower limb, diabetic peripheral angiopathy (disease of the blood vessels because of unregulated diabetes), proteus mirabilis (microorganism causing infection), heart disease, local infection of the skin and peripheral vascular disease (a blood circulation disorder). Record review of Resident #1's MDS dated [DATE] revealed,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff were able to demonstrate competency in the provision of skills and techniques necessary to care for one resident (Resident #2) reviewed for incontinent care in that: -CNA D failed to wipe Resident #2's perineal area using only a front to back motion. - CNA D failed to follow proper procedures by using gloves from her pocket when performing incontinent care. - CNA D failed to follow proper procedures by not changing gloves and hand sanitizing prior to touching clean items. These failures could place residents requiring incontinence care at risk for discomfort, skin breakdown, cross contaminations, and urinary tract infections. Findings included: Resident #2 Record review of Resident #2's Face Sheet dated 08/30/2023, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include left arm fracture, right toe fracture, heart failure, chronic kidney disease state 4, diabetes and cancer of the colon.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 7 residents (Resident #1, Resident #2) reviewed for infection control. -The facility failed to ensure an end cap was in place on one lumen of the double lumen PICC line for Resident #1. - CNA D failed to follow proper procedures by using gloves from her pocket when performing incontinent care. - CNA D failed to follow proper procedures by not changing gloves and hand sanitizing prior to touching clean items. This failure could place residents at risk for infection, injury, and hospitalization. Findings included: Resident #1 Record review of Resident #1's Face Sheet dated 08/29/2023 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include cellulitis (skin infection) of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary physical restraints imposed for the purpose of convenience for 1 of 20 residents (Resident #58) reviewed for restraints, in that: The facility failed to assess the need for half-length side rails for Resident #58 prior to using them. This failure placed residents at risk of being injured as a result of using a physical restraint. Findings included: Record review of the face sheet for Resident #58 revealed a [AGE] year-old male admitted into the facility on [DATE] and diagnosed with Parkinson's disease, overactive bladder and muscle weakness. Record review of Resident #58's MDS, dated [DATE], revealed resident had a BIMS score for cognition was not assessed and the resident was coded to not have bed rails used as a physical restraint. MDS Section G indicated resident needed extensive assistance for transfers and bed mobility. Record review of Resident #58's care plan revealed resident had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to accurately assess each resident's status for 2 of 8 Residents (Resident #41 and #58) reviewed for assessment accuracy in that: - Resident #41's Comprehensive MDS dated [DATE] sections for cognition and mood were not complete. - Resident #58's Comprehensive MDS dated [DATE] did not correctly assess his fall history. This failure placed residents at risk of not receiving the proper care and services due to inaccurate MDS assessments. Findings include : Record review of a face sheet dated 1/19/23 indicated Resident #41 was an [AGE] year-old male admitted on [DATE] with diagnoses of end stage renal disease, hypertensive chronic kidney disease with stage 5 (a medical condition in which a person's kidneys stop functioning on a permanent basis leading for a regular course of long-term dialysis), type 2 diabetes, allergic rhinitis, dependence on renal dialysis, Alzheimer's disease. Record Review of Resident #41's comprehensive MDS dated [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 8 (Residents #41 ) Residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan that described Resident #41's medications that he was able to self-administer. This could place residents at risk of a medication error. Findings include: Record review of a face sheet dated 1/19/23 indicated Resident #41 was an [AGE] year-old male admitted on [DATE] with diagnoses of end stage renal disease, hypertensive chronic kidney disease with stage 5 (a medical condition in which a person's kidneys stop functioning on a permanent basis leading for a regular course of long-term dialysis), type 2 diabetes, allergic rhinitis, dependence on renal dialysis, Alzheimer's disease.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #316) reviewed for urinary catheters in that: The facility failed to ensure Resident #316's urinary catheter bag was off the floor. This deficient practice could affect residents who had urinary catheters and result in trauma or urinary tract infections. Findings include: Review of Resident #316's face sheet, dated 1/19/23, revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet diagnoses list included viral pneumonia (Primary, Admission), acute respiratory failure with hypoxia (low oxygen), (Secondary, admission from recent hospitalization). Further diagnoses included gastritis (inflammation of the stomach), esophagitis (inflammation of the esophagitis), gastrointestinal hemorrhage (a rupture in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASRR for 1of 4 residents, (Residents # 86) reviewed for PASRR Level 1 screenings. The facility did not send the correct PASRR Level 1 (PL1) screening to the local authority for Residents #86. This failure could place residents with positive PASRR at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental and psychosocial well-being. Findings included: Record review of Resident #86's face sheet revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. The resident was [AGE] years old. Her admission diagnoses included: bipolar disorder (mental health disorder that cause extreme mood swings). Record review of Resident #86's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 03 out of 15 indicating severe cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medications errors for one of four residents (Resident #26) reviewed for medications, in that; Med Aide B crushed and administered Resident #26's Potassium Chloride ER 10 mEq medication without MD order to crush the tablet. This failure could place residents at risk for adverse consequences which could cause depleted potassium levels. Findings included: Record review of the facility face sheet revealed Resident #26 was admitted to the facility on [DATE] with a readmission on [DATE]. She was [AGE] years old. Her diagnoses included in part; cerebral infarction (decreased blood flow to brain), chronic atrial fibrillation (irregular, rapid heart rate), heart failure (heart unable to pump blood well), and presence of cardiac pacemaker (small device implanted in chest to help control heartbeat), Dysphagia (difficulty swallowing foods or liquids). Record review of Resident #26's admission MDS assessment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.