West Janisch Health Care Center

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

partial/moderate assistance - helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for

the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of

the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE REDACTED] revealed, a [AGE] year-old female who admitted to the facility on [DATE REDACTED] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder. Record review of Resident #20's Quarterly MSDS dated [DATE REDACTED] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary. Transfer: supervision by staff to move between surfaces Resident #25

Record review of Resident #25's Face Sheet dated [DATE REDACTED] revealed, a [AGE] year-old female who admitted to the facility on [DATE REDACTED] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure.

Depression, dependence on dialysis, and dementia. The resident discharged to the hospital on [DATE REDACTED].

Record review of Resident #25's Discharge MDS dated [DATE REDACTED] revealed, Modified independence. Cognitive skills for daily decision making and set up or clean up assistance with most ADL's. As well as partial to moderate assistance with most functional abilities. Record review of Resident #25's undated Care Plan revealed, Focus: ADL self-care performance deficit and requires cues,setup, and/or assistance with ADLs r/t dx dementia, anxiety, depression; Interventions- Chair/bed-to-chair transfer: resident's usual independent - resident completes the activity with no assistance from a helper. Lying to sitting on side of bed- resident's usual independent - resident completes the activity with no assistance from a helper. Roll left and rightresident's usual independent - resident completes the activity with no assistance from a helper. Sit to lyingresident's usual independent - resident completes the activity with no assistance from a helper. Sit to

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Janisch Health Care Center

617 W Janisch St Houston, TX 77018

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and right: resident's usual performance is dependent - Helper does all of the effort. Resident does none of

the effort to complete the activity. Sit to lying: Resident's usual performance is partial/moderate assistance helper does less than half of the effort. helper lifts, holds, or supports trunk or limbs but provides less than half the effort. Sit to stand: Resident's usual performance is dependent the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more is required for the resident to complete the activity. Wheel 50 feet with two turns (specify: manual or motorized wheelchair): resident's usual performance is dependent - helper does all of the effort. resident does none of the effort to complete the activity. Resident #20 Record review of Resident #20's Face Sheet dated [DATE REDACTED] revealed, a [AGE] year-old female who admitted to the facility on [DATE REDACTED] with diagnoses which included: Alzheimer's disease, dementia and Major depressive disorder. Record review of Resident #20's Quarterly MSDS dated [DATE REDACTED] revealed, Short term and long term memory OK, modified independent cognitive skills for daily decision making, no behaviors, no upper or lower extremity functional limitations in range of motion, use of the wheelchair, and total dependence for all ADL's and functional abilities. Record review of Resident #20's undated Care Plan revealed, Focus- Risk for Injury Due to potential elopement as evidenced by exit; Interventions- Assess quarterly for continued use of wander guard bracelet. Focus: ADL self-care performance deficit r/t; Alzheimer's; Interventions: Bed mobility: supervision by staff to turn and reposition in bed and as necessary.

Transfer: supervision by staff to move between surfaces Resident #25 Record review of Resident #25's Face Sheet dated [DATE REDACTED] revealed, a [AGE] year-old female who admitted to the facility on [DATE REDACTED] with diagnoses which included: type 2 diabetes, high cholesterol, kidney failure. Depression, dependence on dialysis, and dementia. The resident

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Janisch Health Care Center

617 W Janisch St Houston, TX 77018

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

person assist and was transferred using a Hoyer lift. In an interview on [DATE REDACTED] at 08:24 PM, the MDS Nurse said she was responsible for completing all facility MDSs. She said the MDA represents the resident's status and is usually a 7 day look back period. She said a resident's functional limitation in range of motion documents how a resident performs their day to day activities. She said failure to have the correct diagnosis or an incorrect MDS placed residents at risk for missed services and an inaccurate plan of care. The MDS said CR #44 had paralysis on one side of her body. After she reviewed the MDS, she said CR #44's MDS was coded incorrectly because it did not document her paralysis as a functional limitation of range of motion. She said she was responsible for completing CR #44's diagnosis, MDS and care plan and the errors were an oversight.Record review of Resident #28's face sheet dated [DATE REDACTED], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE REDACTED] with diagnoses including Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities).Record review of Resident #28's quarterly MDS dated [DATE REDACTED] revealed a BIMS score of 0 that indicated severe cognitive impairment.

Record review of Resident #28's unmodified quarterly MDS dated [DATE REDACTED] revealed wandering behavior was not exhibited in Section E. Record review of Resident #28's modified quarterly MDS dated [DATE REDACTED] of Section E revealed wandering behavior occurred 1 to 3 days. Section P revealed daily use of wander/elopement alarm.Record review of Resident #28's Order Summary Report as of [DATE REDACTED] revealed WANDER DEVICE: Wander device alarm applied with order date of [DATE REDACTED]. Record review of Resident #28's care plan with revision date of [DATE REDACTED] and target date of [DATE REDACTED] revealed Resident #28 was care planned with a focus of requiring a wander guard bracelet and was at risk for injury from wandering. Record

review of Resident #28's Elopement Risk Screener dated [DATE REDACTED] revealed Resident #28 had a wandering history but had never eloped. Record review of Resident #28's [DATE REDACTED] TAR revealed task from 9/1-[DATE REDACTED] to visually check placement of Wandering Alert Device every shift from 9/1-[DATE REDACTED].Observation on [DATE REDACTED] at 12:24 p.m. revealed Resident #28 walking up and down the #400 hallwayDuring interview on [DATE REDACTED] at 2:15 p.m., CNA M said Resident #28 walked a lot and would walk back and forth in every hallway. Observation

on [DATE REDACTED] at 2:19 p.m. revealed Resident #28 walking down the #100 hallway when her room was on the #400 hallway. During interview on [DATE REDACTED] at 2:33 p.m., MDS RN said the Social Services Director completed Section E of the MDS and showed the surveyor Section P where use of wander/elopement alarm was captured. During interview on [DATE REDACTED] at 2:41 p.m., the DON said she was familiar with Resident #28, and she walks all day. The DON said the MDS RN was responsible for completing the MDS. The DON said if the MDS was not accurate it was not a direct accurate reflection of who the resident was. During

interview on [DATE REDACTED] at 2:47 p.m., the MDS RN said she was going to modify Resident #28's MDS. During

interview on [DATE REDACTED] at 4:07 p.m., the Social Services Director answered yes when asked if Resident #28 wandered. The Social Services Director said she completed sections B, C, D, E and Q of the MDS. The Social Services Director said she documented that wandering behavior was not exhibited as Resident #28 walks the hallways but did not wander outside. The Social Services Director said Resident #28 had a wanderguard and she was not sure what happened prior for Resident #28 to get the wanderguard. The Social Services Director said something must have happened for the resident to be at risk for the wanderguard. The Social Services Director said if the MDS did not reflect the resident accurately then that was false information because you would not be looking for those behaviors. Record review of the facility's policy MDS 3.0 Completion dated 2023 revealed According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Janisch Health Care Center

617 W Janisch St Houston, TX 77018

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

come off the resident's care plan when the wound was resolved. During an interview on 10/3/25 at 3:10 p.m., ADON said she completed the baseline care plans for new admissions. ADON said the previous DON preferred to update the care plans and attended the care plan meetings. ADON said the MDS RN was responsible for completing the MDS. During an interview on 10/3/25 at 5:23 p.m., LVN C, who was the current wound care nurse, said she was only responsible for wound care and not updating the resident's care plans. LVN C said probably DON or ADON was responsible for updating the residents' care plans regarding wound care. Record review of facility's policy Comprehensive Care Plans dated 2025 revealed

The comprehensive care plans will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

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Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Janisch Health Care Center

617 W Janisch St Houston, TX 77018

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

maximum assistance for most mobility. Total dependence for mobility with manual wheelchair for 50- 150 feet. Record review of Resident #48's undated Care Plan revealed, Focus: a self-care performance deficit r/t requires extensiveto total assistance r/t dementia, late effects of CVA, aphasia, bedbound, incontinence; Interventions: locomotion: utilizes a wheelchair when for proper positioning r/t impaired sitting balance and poor trunk control. Extensive assistance by one-two staff to turn and reposition in bed and wheelchair. Lift and extensive assistance by two staff to transfer at all time. Resident #54 Record review of Resident #54's Face Sheet dated [DATE REDACTED] revealed, a [AGE] year-old male who admitted to the facility on [DATE REDACTED] with diagnoses which included: Quadriplegia (paralysis that affects all limbs), anxiety disorder, weakness, and difficulty swallowing. The residents advanced directive was full code. Record review of Resident #54's Annual MDS dated [DATE REDACTED] revealed, moderately impaired cognition as indicated by a BIMS score of 8 out of 15, use of a wheelchair, upper and lower body, total dependence for all self-care, mobility, and quadriplegia. Record review of Resident #54's undated Care Plan revealed, focus: full code; interventions: appropriate care within guidelines of advanced directives; should [resident #54] be found with no pulse, respirations, or blood pressure, start CPR & call 9-1-1 immediately. Focus: ADL self-care performance deficit and requires cues setup, and/or assistance with ADLs r/t quadriplegia; interventions: usual performance is dependent - helper does all of the effort. [resident #54] does none of the effort to complete

the activity or the assistance of 2 or more is required for [resident #54] to complete the activity. lying to sitting on side of bed: [resident #54]'s usual performance is dependent - helper does all of the effort. [resident #54] does none of the effort to complete the activity or the assistance of 2 or more is required for

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/07/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Janisch Health Care Center

617 W Janisch St Houston, TX 77018

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

meal. There was not a side served with the soup other than cottage cheese with fruit syrup on it. No fruit was served. The [NAME] reported that she cooks whatever the Dietary Director tells her is the meal. The menu is not posted in the kitchen.Review of the Menu board posted outside of the dining room on 10/03/25 at 10:06 AM revealed the following:lunch menu for the day: oven fried chicken, okra/tomato, rice, cornbread, cake with whipped topping.dinner menu: Enchiladas, southwest salad, black beans, apple slices.Review of

the Menu board posted outside of the dining room on 10/04/25 at 11:26 AM revealed the following:lunch menu for the day: pork loin, au gratin potatoes, Malibu vegetable blend, rolls, chocolate chip cookies. dinner menu: Unstuffed peppers, green beans, bread, apple slices. In an interview on 10/06/25 at 12:08 PM with

the Registered Dietitian for the facility, she revealed the approvals for changes of the weekly menu were made by the Regional Registered Dietitian and she had not approved any menu changes made by the Dietary Director.In an interview on 10/07/25 at 10:16 AM with the Regional Registered Dietitian, she reported the menu process is that the vendor sends out Spring and Summer menus. The facility started using them for menus in February of this year. She reported that they try to focus on residents' choices.

They have a food committee of residents that meet and the upcoming menu is reviewed. The resident council can submit feedback on the meals as well. Their feedback is used in decision making to change menu items but they stay within the same nutritional value. The protein will stay the same and swap a vegetable for a vegetable. They have a substitution log that should be completed and signed off by the Registered Dietitian. She was not aware if there was a specific food committee at the facility. She reported

they always have an alternate menu available. Residents should be offered what is on the printed menu or

a substitute of equal nutritional value.In an interview on 10/07/25 at 12:26 PM with the Administrator, she reported she was not aware that the Dietary Director was not following the weekly printed menu and substitutions were being made without appropriate approval. She reported she will ensure the menus and meal preparations are carried out following the policies going forward.Record review of the facility policy, Menus and Adequate Nutrition, 2025 revision, revealed: Policy section titled Policy Explanation and Compliance Guidelines: 3. Menus shall be prepared at least two weeks in advance for timely approval and ordering of food. Menus will be posted in the kitchen and in areas accessible by residents at least one week

in advance. 4. Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitutions shall comprise of foods with comparable nutritive value.8. The facility's dietitian or other clinically qualified nutrition professional will review all menus for nutritional adequacy and approve the menus.

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