The Grace Care Center Of Katy

F-F921 Other References Related Documents Version 1.2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0584 Record review of revised date April 2010 policy titled: Work Orders, Maintenance Policy Statement. Maintenance work orders shall be completed in order to establish a priority of maintenance service. Policy Level of Harm - Minimal harm or Interpretation and Implementation1. In order to establish a priority of maintenance service, work orders must potential for actual harm be filled out and forwarded to the Maintenance Director. 2. It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director. 3. A supply of work orders is Residents Affected - Some maintained at each nurses' station. 4. Work order requests should be placed in the appropriate file basket at

the nurses' station. Work orders are picked up daily. 5. Emergency requests will be given priority in making necessary repairs.

The facility did not have a specific policy that addressed linen and towels.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or 48923 potential for actual harm Based on record review and interview, the facility failed to develop and implement written policies and Residents Affected - Some procedures that prohibit and prevent abuse, neglect, and exploitation of residents, including screening for 1 of 25 staff reviewed for abuse.

-The DON did not have an annual EMR (Employee Misconduct Registry) check conducted between 07/28/2023 and 01/09/2025.

This can put residents at risk of abuse, neglect and exploitation by receiving care from staff members who were unemployable.

Findings included:

Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy statement last revised revealed that the facility's abuse, neglect, and exploitation prevention program consisted of developing and implementing policies and protocols to prevent and identify abuse or mistreatment and conducting employee background checks and not unknowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect or had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation or mistreatment of residents or had a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, or mistreatment of residents or resident property .

Record review of the DON's personnel file, he was hired on 06/20/2023 and his annual EMR check in his file was 07/28/2023 which showed he was employable. His next check was 01/09/2025 which was completed

after it was brought to the facility's attention, and it showed the DON was employable.

Interview with the HR Coordinator on 1/9/2025 at 2:50pm, she said that the DON's last background check was completed at 7/28/2023. She said she conducted a background check on 01/09/2025 because this was brought to her attention and the Administrator told her to go ahead and do the check. She said background checks are to be done annually and that she is responsible for completing them. The HR Coordinator said

the facility did annual checks to make sure there was nothing on a person's record and to avoid accidentally hiring a criminal. She also said that her missing it must have been an oversight.

Interview with the ED (Executive Director) on 1/10/2025 at 1:33pm, he said he was not sure if employee background checks needed to be completed on an annual basis. But if that was a requirement by the State, then anyone who had been barred from employment would continue to be able to work and that would put

the facility out of compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35822

Residents Affected - Few 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 restore continence to the extent possible for 1 of 6 residents (Resident #68) reviewed for incontinent care.

1. CNA I failed to provide incontinent care for Resident #68 at least every 2 hours.

2. CNA I failed to thoroughly clean Resident #68 when providing incontinent care

These failures could place residents at risk for urinary tract infections, hospitalization and decrease in quality of life.

Findings include:

Record review of Resident #68's face sheet, dated 01/09/25, revealed a [AGE] year-old female who was admitted to the NF on 08/02/23. The resident had diagnoses which included: heart disease, depression, prediabetes, acute cystitis (bladder infection that develops suddenly), hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side and, aphasia (language disorder that affects a person's ability to communicate).

Record review of Resident #68's Annual MDS, dated [DATE REDACTED], revealed a BIMS coded as 99, which meant unable to complete the interview. Section GG (functional abilities) reflected the resident was dependent with toileting hygiene. Section H (bladder and bowel) reflected the resident was always incontinent of urine and bowel.

Record review of Resident #68's care plan revealed the resident was care planned for urinary tract infection 10/21/24-10/28/24 with intervention to check the resident at least every 2 hours for incontinence, was h, rinse, and dry soiled areas . good hygiene practices clean peri area well after bowel movements in order to help prevent bacteria in the urinary tract.

Observation on 01/09/25 at 2:10 PM of incontinent care for Resident #68 by CNA I and CNA J revealed the resident's brief was heavily soiled with urine so much, the urine extended to the resident's lower back and

the draw sheet was soiled. Resident #68's was also soiled with feces. Further observation of Resident #68's incontinence care performed by CNA I, CNA I used disposable wipes and did not thoroughly clean the resident's vaginal region area, leaving the residual of feces .

Interview on 01/09/25 at 2:23 PM, CNA I said the last time she provided incontinent care for Resident #68 was around 11:15 AM or 11:30 AM. CNA I said incontinent care was supposed to be provided to the residents at least every 2 hours to prevent skin breakdown and infections such as urinary tract infections .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0690 Interview on 01/09/25 at 2:30 PM, RN K said he was Resident #68's nurse. Resident #68 said he normally checked on the residents every 2 hours to ensure the residents were being provided incontinent care in a Level of Harm - Minimal harm or timely manner. RN K said the last time he had checked on Resident #68 was at 11:00 AM and she did not potential for actual harm require incontinent care .

Residents Affected - Few Interview and record review on 01/09/25 at 4:15 PM, the DON said the nursing staff should be providing incontinent care to the residents every 2 hours. The DON was asked for the NF policy on female incontinence. The NF provided an in-service done with CNA I on Competency Assessment for Perineal Care of the female, dated 01/09/25 and reflected in part: .The purpose is to clean the female perineum (area of the skin between the anus {rectum) and the genitalia) without contaminating the urethral (tube that carries urine from the bladder to outside of the body) area with germs

Record review of the facility's policy on Incontinent Care for Females, last revised February 2018, reflected in part, For a female resident, wet washcloth and apply soap for skin cleansing agent and wash perineal area, wiping front to back .wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48923 potential for actual harm Based on observation. interview and record review, the facility failed to ensure that a resident who needs Residents Affected - Few respiratory care is provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #63) reviewed for oxygen.

- The facility failed to place Resident #63's oxygen tubing inside of bag when not in use.

- The facility failed to change Resident #63's oxygen tubing after the tubing was observed on floor on 01/07/25.

- The RN F failed to dispose of Resident #63's oxygen tubing to prevent infections on 01/08/25.

This failure could put residents at risk of not receiving consistent respiratory care and lead to a decline in health.

Findings included:

Record review of Resident #63 face sheet, dated 01/09/25, revealed an [AGE] year-old female who was admitted to the NF on 09/13/21. Resident #63 had diagnoses which included: aphakia bilateral (condition where both eyes lack natural lens due to surgically removal), respiratory failure with hypoxia (absence of oxygen), pacemaker and heart disease.

Record review of Resident #63's Care Plan, dated 03/21/22 and revised 10/08/24 reflected the resident was care planned for O2. The interventions included oxygen per nasal cannula as needed.

Record review of Resident #63's Comprehensive MDS, dated [DATE REDACTED] , revealed the resident had a BIMS score of 15, which indicated the resident's cognition was intact. Section O (special treatments, procedures, and programs) resident was coded for receiving respiratory treatment.

Record review of Resident #63's Physician Order Summary Report for the month of January reflected the following order:

-Dated 10/22/21 O2 at 2L via nasal cannula q HS at bedtime for possible sleep apnea.

Observation on 01/07/25 at 10:40 AM of Resident #63's room revealed the oxygen machine on the right side of the bed with tubing connected to the oxygen machine. The oxygen tubing was dated 01/06/25 and laid on

the floor not inside of bag.

Observation on 01/09/25 at 9:08 AM, revealed Resident #63 was not wearing her oxygen tubing. The resident's oxygen tubing was draped across the oxygen machine not inside of a bag. The date on the oxygen tubing read 01/06/25.

Observation on 01/09/25 at 9:12 AM revealed RN F removed Resident #63's tubing from the room without donning clean gloves. RN F did not place the tubing inside of a bag and proceeded to take the tubing out of

the resident room and walked down the hallway.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0695 Interview on 01/09/25 at 9:10AM with RN F said she was the nurse for Resident #63. When asked about resident oxygen tubing, RN F went to resident room to remove the oxygen tubing that read 01/06/25 draped Level of Harm - Minimal harm or over the oxygen tubing. potential for actual harm

Interview on 01/09/25 at 9:22 AM, RN F said the oxygen tubing should be placed inside of a plastic bag Residents Affected - Few when not in use. RN F said she should have placed gloves on prior to touching the tubing and placed it in a bag before leaving the room to dispose of the tubing for infection control. RN F said she was not aware Resident #63 was on oxygen and apologized for the failure of infection control while not placing gloves on prior to touching the tubing.

Interview on 01/09/25 at 11:20 AM, the NF Infection Control said she started working at the NF on 12/15/24.

The NF Infection Control Nurse also said whenever a resident's oxygen was not in use, the oxygen tubing should be placed inside of bag to prevent infections. The Infection Control Nurse said when removing oxygen tubing from the room, the staff should don gloves and place the tubing inside of a bag and tie the bag, take

the gloves off and wash their hands and dispose of the used tubing for infection control and preventing cross-contamination.

Record review of the facility's policy for Infection Control, revised October 2018, revealed in part:

.This facility infection control policy and practices are intended to facilitate maintaining a safe sanitary and comfortable environment and to help prevent an manage transmission of diseases and infections

Record review of the facility's policy for Administering Medications revised , revealed in part:

Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 48923

Residents Affected - Some Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 2 medication storage rooms reviewed for pharmaceutical services.

The facility failed to ensure there was not 5 expired heparin flushes (6 ml), dated 07/2024, in their medication room on the long-term care hall.

This failure could place residents at risk for medication not being therapeutic, effective, or unwanted adverse reaction decreasing the quality of life.

Findings include:

Observation on 01/08/25 at 10:35AM in the medication room on the long-term care hall had 5 syringes of heparin flush (6ml) had an expiration date of 07/2024 with no additional external labels.

Interview on 01/08/25 at 10:43 AM, RN E said she was not sure who was responsible for checking the medication room on the long-term care hall for expired medications. RN E said no one at the facility had a PICC or midline and the last person to have a PICC/midline was a few months ago. RN E said the resident no longer resided at the facility. RN E said an expired heparin flush would not be therapeutic if administered

after its expiration date. RN E said it was important to check the medication room for any expired medications to avoid a medication error.

Interview on 01/08/25 at 11:47AM, the DON said the night nurse was responsible for checking the medication room for expired medications. The DON said the ADON also checked the medication room for expired medications. The DON said an expired heparin flush would no longer be viable to administer.

Interview on 01/08/25 at 1:00 PM, the ADON said she checked the medication rooms 2-3 times a week for expired medications on Monday, Wednesday, and Friday. The ADON said all expired medications should be place inside of the biohazard bind for pharmacy drug destruction. The ADON said the pharmacy came to the NF once a month and more often if needed. The ADON said if a resident was administered an expired medication, the resident was placed at risk for an adverse reaction and the drug not being effective for its intended use.

Attempted interview on 01/08/25 at 1:08 PM with the night nurse for the long-term care hall was unsuccessful and a voicemail was left with a call back number . The night nurse did not return the call.

Record review of the facility's policy on Discarding & Destroying medications, revised November 2022, revealed in part:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0755 .Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceutical, hazardous Level of Harm - Minimal harm or waste and controlled substance potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35822 potential for actual harm Based on observation, interview and record review the facility failed to establish and maintain an infection Residents Affected - Some 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 3 of 8 residents (Residents #63, #68 and #195) reviewed for infection control .

1. The facility failed to place infection control signage on Resident # 195's door until 01/08/25, 2 days after

the resident was admitted to the NF on 01/06/25 with an indwelling Foley catheter and lesions on her body.

2 The facility failed to place Resident #63's oxygen tubing inside of bag when not in use.

3. The facility failed to change Resident #63's oxygen tubing after the tubing was observed on floor on 01/07/25.

4. RN F failed to dispose of Resident #63's oxygen tubing to prevent infections on 01/08/25.

5. CNA I and CNA J failed to don in full PPE on 01/09/25 while providing incontinent care for Resident #68, who had a gastrostomy tube.

These failures could place residents at risk for cross contamination, infections, and a decrease in quality of life.

Findings include:

1. Record review of Resident #195's face sheet, dated 01/09/25, revealed an [AGE] year-old female who was admitted to the NF on 01/06/25. Resident #195 had diagnoses which included cognitive communication deficit and need assistance with personal care.

Record review of Resident #195's hospital records, dated 01/04/25, reflected the following diagnoses: hypertension (high blood pressure), diabetes mellitus (too much sugar in the blood), cellulitis (bacterial skin infection), multiple superficial (on the surface) skin wounds and excoriations (skin lesions caused by repetitive picking, scratching, or rubbing of the skin) and urinary tract infection (infection of any part of the system of organs that makes urine).

Record review of Resident 195's MDS, the resident was recently admitted and the MDS was not completed.

Record review of Resident #195's Baseline Care Plan, dated 01/06/25, reflected antibiotic therapy, indwelling Foley catheter and skin integrity . The baseline care plan did not contain additional information such as interventions.

Record review of Resident #195's Physician Order Summary Report for January 2025 reflected the following orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0880 -Dated 01/07/25 Bactrim DS (double strength) tablet 800-160mg give one tablet by mouth two times a day for urinary tract infection for 5 days Level of Harm - Minimal harm or potential for actual harm -Dated 01/07/25 Foley catheter

Residents Affected - Some -Dated 01/07/25 Clobetasol Propionate external cream (reduces swelling, redness, itching, or rashes cause by a skin condition) 0.05% apply to all affected areas topically one time a day for bullous pemphigoid (rare skin condition causing large, fluid-filled blisters) due to autoimmune disease (disease in which the body 's immune system attacks healthy cells).

Record review of Resident #195's Wound Progress Note, dated 1/7/25, reflected the following:

-Chief Complaint: Patient with wounds on her left arm, right leg

-Skin Exam: Wound to left lower extremity, left upper extremity, right upper extremity, right lower extremity

-Etiology (cause): Autoimmune disease

Observation on 01/07/24 at 9:34 AM of Resident #195's door revealed no infection control signage on the door or any PPE outside the doorway entrance. Further observation of resident revealed lesions on her neck and arms. The resident had an indwelling Foley catheter draining clear yellow urine in the tubing.

Observation on 01/08/25 at 8:30 AM of Resident #195's door revealed no infection control signage on the door and no PPE outside of door.

Observation on 01/09/25 at 8:00 AM of Resident #195's door revealed no infection control signage on her door with PPE inside of a plastic bend outside of her doorway entrance .

Interview on 01/08/25 at 9:34 AM, Resident #195 said she arrived at the NF on 01/07/25 at night from the hospital. The resident said she had sores all over her body. Resident #195 said she had the lesions for a while, and they sometimes had drainage .

Interview on 01/09/25 at 8:57AM, RN F said she was the nurse for Resident #195. RN F said it was the Infection Control Nurse who was responsible for placing the infection control signage on resident doors who required it. RN F said she suspected the signage was on the resident's door due to the resident being admitted with a urinary tract infection.

Interview on 01/09/25 at 11:20 AM, the Infection Control Nurse said she started working at the NF on 12/15/24. The Infection control Nurse said she was responsible for placing the infection control signage on

the resident doors. The Infection Control Nurse said she placed the infection control sign on Resident #195 door on the night of 01/08/25 due to the resident having lesions with some drainage. The Infection Control Nurse said infection control signage was placed on resident doors who had wounds, IV's , gastrostomy tubes, Foley catheters, urinary tract infections, etc . The Infection Control Nurse said this was done to decrease the risk of cross contamination for the residents as well as the staff. The Infection Control Nurse said the staff should be wearing PPE when providing care for the resident's which consisted of disposable gown, gloves, etc .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0880 2. Record review of Resident #63 face sheet, dated 01/09/25, revealed an [AGE] year-old female who was admitted to the NF on 09/13/21. Resident #63 had diagnoses which included: aphakia bilateral (condition Level of Harm - Minimal harm or where both eyes lack natural lens due to surgically removal), respiratory failure with hypoxia (absence of potential for actual harm oxygen), pacemaker and heart disease.

Residents Affected - Some Record review of Resident #63's Care Plan, dated 03/21/22 and revised 10/08/24 reflected the resident was care planned for O2. The interventions included oxygen per nasal cannula as needed.

Record review of Resident #63's Comprehensive MDS, dated [DATE REDACTED] , revealed the resident had a BIMS score of 15, which indicated the resident's cognition was intact. Section O (special treatments, procedures, and programs) resident was coded for receiving respiratory treatment.

Record review of Resident #63's Physician Order Summary Report for the month of January reflected the following order:

-Dated 10/22/21 O2 at 2L via nasal cannula q HS at bedtime for possible sleep apnea.

Observation on 01/07/25 at 10:40 AM of Resident #63's room revealed the oxygen machine on the right side of the bed with tubing connected to the oxygen machine. The oxygen tubing was dated 01/06/25 and laid on

the floor not inside of bag.

Observation on 01/09/25 at 9:08 AM, revealed Resident #63 was not wearing her oxygen tubing. The resident's oxygen tubing was draped across the oxygen machine not inside of a bag. The date on the oxygen tubing read 01/06/25.

Observation on 01/09/25 at 9:12 AM revealed RN F removed Resident #63's tubing from the room without donning clean gloves. RN F did not place the tubing inside of a bag and proceeded to take the tubing out of

the resident room and walked down the hallway.

Interview on 01/09/25 at 9:10AM with RN F said she was the nurse for Resident #63. When asked about resident oxygen tubing, RN F went to resident room to remove the oxygen tubing that read 01/06/25 draped over the oxygen tubing.

Interview on 01/09/25 at 9:22 AM, RN F said the oxygen tubing should be placed inside of a plastic bag when not in use. RN F said she should have placed gloves on prior to touching the tubing and placed it in a bag before leaving the room to dispose of the tubing for infection control. RN F said she was not aware Resident #63 was on oxygen and apologized for the failure of infection control while not placing gloves on prior to touching the tubing.

3. Record review of Resident #68's face sheet, dated 01/09/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE REDACTED]. Resident #68 had diagnoses which included: heart disease, depression (condition where a person has prolonged low mood and loss of interest in activities), prediabetes (blood sugar levels are higher than normal but does not have diabetes, which is when blood sugar is not properly processed by the body), acute cystitis (bladder infection that develops suddenly), hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, gastrostomy (feeding tube that is surgically inserted into the stomach through the abdomen), and aphasia (language disorder that affects a person's ability to communicate).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 22 676195 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676195 B. Wing 01/10/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Falcon Point Post Acute 23553 West Fernhurst Drive Katy, TX 77494

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 0880 Record review of Resident #68's care plan, dated 04/24/24 , reflected the resident was being care planned for gastrostomy tube. Intervention included possibly infected with an MDRO due to constant placement of Level of Harm - Minimal harm or indwelling medical device (G-tube) intervention: Team member will wear PPE (gown and gloves) while potential for actual harm providing high contact care activities such as bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Residents Affected - Some

Record review of Resident #68's Annual MDS, dated [DATE REDACTED] , revealed a BIMS coded at 99, which meant

the resident was unable to complete the interview. Section GG (functional abilities) reflected the resident was dependent with toileting hygiene. Section H (bladder and bowel) reflected the resident was always incontinent of urine and bowel.

Observation on 01/09/25 at 2:05 PM revealed Resident #68 had infection control signage on the door entrance.

Observation on 01/09/25 at 2:10 PM of incontinent care for Resident #68 by CNA I and CNA J entered resident room to provide care. Both CNA's washed hands and placed on clean gloves but not a gown and proceeded to care for resident. Resident had a gastrostomy tube. Resident brief was heavily soiled with urine so much, that the urine extended to resident lower back torso with the draw sheet being soiled as well. Resident was also incontinent of feces.

Interview on 01/09/25 at 11:20 AM, the NF Infection Control said she started working at the NF on 12/15/24.

The Infection Control Nurse said infection control signage was placed on resident doors that had wounds, IV's, gastrostomy tubes, Foley catheters, urinary tract infections, etc. The Infection Control Nurse said this was done to decrease the risk of infections and cross contamination from resident to resident and the staff.

The Infection Control Nurse said the staff should be wearing PPE when providing care for the residents that consisted of disposable gown, gloves, etc. The NF Infection Control Nurse also said whenever a resident's oxygen was not in use, the oxygen tubing should be placed inside of bag to prevent infections. The Infection Control Nurse said when removing oxygen tubing from the room, the staff should don gloves and place the tubing inside of a bag and tie the bag, take the gloves off and wash their hands and dispose of the used tubing for infection control and preventing cross-contamination.

Interview on 01/09/25 at 3:36 PM, CNA I said she forgot to don in full PPE for infection control when providing care for Resident #68 .

Interview on 01/09/25 at 3:45 PM, CNA J said she forgot to don in full PPE for infection control when she assisted CNA with providing incontinent care for Resident #68.

Record review of the facility's policy for Infection Control, revised October 2018, revealed in part:

This facility infection control policy and practices are intended to facilitate maintaining a safe sanitary and comfortable environment and to help prevent an manage transmission of diseases and infections .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 22 676195