Regent Care Center Of League City

F-F695 Respiratory/Tracheostomy Care and Suctioning

[DATE REDACTED] at 7:11pm

Immediate Response:

o The identified resident expired on [DATE REDACTED].

o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen.

Date completed: [DATE REDACTED].

o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for

the resident. The Director of Nursing Services/Assistant Director of Nursing will supervise this process and monitor ,d+[DATE REDACTED] days a week for the next 2 months.

Date completed:[DATE REDACTED].

o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders.

Date completed: [DATE REDACTED].

o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored , d+[DATE REDACTED] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services.

Date of completed: [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 32 676153 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 676153 B. Wing 01/13/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Level of Harm - Immediate Nursing. This process will be monitored ,d+[DATE REDACTED] days a week for the next 2 months by the Director of jeopardy to resident health or Nursing Services/Assistant Director of Nursing Services. safety Date of completed: [DATE REDACTED]. Residents Affected - Some o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored ,d+[DATE REDACTED] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services.

Date of completion: [DATE REDACTED]

o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition).

The nurse will immediately assess the resident and document in the electronic health record, notify the physician and responsible party. The charge nurse will proceed with any new orders from the physician.

Date of completion: [DATE REDACTED]

o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the Kardex to be informed of the residents needs with activities of daily living prior to providing care of the resident.

Date of completion: [DATE REDACTED]

o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with

the admitting physician in the community. The RN supervisor will monitor this process on weekends, holidays, and when the Director of Nursing Services or Assistant Director of Nursing Services is not present

in the community.

Date completed: [DATE REDACTED].

Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care.

Risk Response:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 32 676153 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 676153 B. Wing 01/13/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 All new admissions/readmissions have the potential to be affected by the deficient practice.

Level of Harm - Immediate Systemic Response: jeopardy to resident health or safety o Director of Nursing Services/Assistant Director of Nursing Services identified all residents in the community (12) on continuous oxygen and verified accurate orders were in the electronic health record. All residents Residents Affected - Some with supplemental oxygen (7) have orders in place in the electronic health record. There were no other residents identified in the community who require continuous/supplemental oxygen.

Date completed: [DATE REDACTED].

o Director of Nursing Services/Assistant Director of Nursing Services provided immediate education to all licensed nurses for the process of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for

the resident.

Date completed:[DATE REDACTED].

o Director of Nursing Services/Assistant Director of Nursing services will conduct skills validations for all licensed nurses to validate competency for inputting physician orders.

Date completed:[DATE REDACTED].

o Rehabilitation Director will be present in the morning meeting. Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored , d+[DATE REDACTED] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services.

Date of completed: [DATE REDACTED].

o Director of Nursing/Assistant Director of Nursing will provide 100% education to all team members in therapy on notification of changes on condition to the Charge nurse/Assistant Director of Nursing/Director of Nursing. This process will be monitored ,d+[DATE REDACTED] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services.

Date of completed: [DATE REDACTED].

o Director of Nursing/Assistant Director of Nursing will provide education to all direct care staff on notification of changes in condition to report to the charge nurse/Assistant Director of Nursing/Director of Nursing Services. This process will be monitored ,d+[DATE REDACTED] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services.

Date of completion: [DATE REDACTED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 32 676153 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 676153 B. Wing 01/13/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 o Director of Nursing/Assistant Director provided 100% education to all licensed nurses in regard to resident's changes in condition (shortness of breath, low oxygen saturations and all changes in condition). Level of Harm - Immediate The nurse will immediately assess the resident and document in the electronic health record, notify the jeopardy to resident health or physician and responsible party. The charge nurse will proceed with any new orders from the physician. safety Date of completion: [DATE REDACTED] Residents Affected - Some o Director of Nursing/Assistant Director provided 100% education to all direct care team members on use and access of the Kardex to be informed of the residents needs with activities of daily living prior to providing care of the resident.

o Date of completion: [DATE REDACTED]

o Director of Clinical Operations provided education to the Director of Nursing Services and Assistant Director of Nursing Services on process and expectation of reconciliation of physician orders from the discharging facility. The charge nurse will then notify the md/np of the admission and review the hospital discharge orders. After this is completed with the md/np, the charge nurse will then enter orders into the electronic health record in PCC for the resident. Director of Nursing Services/Assistant Director of Nursing Services will conduct chart audits the next day of all admissions/readmissions to validate accurate orders were entered into the Electronic Health Record using the hospital discharge summary in collaboration with

the admitting physician in the community.

Date completed: [DATE REDACTED].

Community will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. The community will ensure all residents who require respiratory care are provided such care.

Monitoring Response:

o The Director of Nurses/Assistant Director of Nurses will conduct weekly skills validations of order entry for , d+[DATE REDACTED] nurses, ,d+[DATE REDACTED] days a week for 2 months.

o Director of Nurses/Assistant Director of Nurses will review all admission/re-admission orders daily in the clinical meeting to validate orders are transcribed per discharge orders for the reconciliation process for , d+[DATE REDACTED] days a week for 2 months.

o Director of Nursing Services/Assistant Director of Nursing Services will review all residents who are on oxygen in the morning meeting. A review of residents who are on oxygen will be reviewed with the rehabilitation representative. In addition, the Audit Listing Report for residents on oxygen will we be printed, and a copy given to therapy. This process will be monitored ,d+[DATE REDACTED] days a week for the next 2 months by

the Director of Nursing Services/Assistant Director of Nursing Services.

o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with ,d+[DATE REDACTED] random therapy team member ,d+[DATE REDACTED] days a week for the next 2 months by the Director of Nursing Services/Assistant Director of Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 676153 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 676153 B. Wing 01/13/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 o Director of Nursing/Assistant Director of Nursing will validate the process of reporting changes in condition with ,d+[DATE REDACTED] random therapy team member ,d+[DATE REDACTED] days a week for the next 2 months by the Director Level of Harm - Immediate of Nursing Services/Assistant Director of Nursing Services. jeopardy to resident health or safety o Director of Nursing Services/Assistant Director of Nursing Services will validate the proper process of use/access of the Kardex by ,d+[DATE REDACTED] direct care staff ,d+[DATE REDACTED] days a week for 2 months. Residents Affected - Some o Director of Nursing Services/Assistant Director of Nursing Services will validate the process to implement with the notification of a change in condition from ,d+[DATE REDACTED] random licensed nurses ,d+[DATE REDACTED] days a week for 2 months.

o All the monitoring will be monitored by the Director of Nursing/Assistant Director of Nursing.

This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months.

Medical Director notified of the Immediate Jeopardy on [DATE REDACTED] @ 7:22pm per Director of Nursing Services.

Surveyor monitored the plan of removal for effectiveness as follows:

Observation and interviews starting from [DATE REDACTED] to [DATE REDACTED] revealed no concerns with oxygen therapy for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. There were no signs of shortness of breath or labored breathing, each resident received oxygen therapy within the parameters of their physician order.

Record review of physician orders and care plans for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed no concerns, each resident had physician orders and were care planned for oxygen therapy.

Record review of [DATE REDACTED] to [DATE REDACTED] oxygen saturations and MAR/TAR's for Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 revealed each resident was being monitored for oxygen therapy.

Record review of the facility plan or removal training, skills check-off, and in-service revealed the facility had 12 residents on oxygen, and the DON reviewed and completed their clinical records on [DATE REDACTED].

Record review of the facility training revealed that the corporate nurse trained the DON, nurse managers, and administrator on physician follow-up chart checks, completed on [DATE REDACTED].

Record review of the facility training for the nurses on medication reconciliation with the physician from discharged facility order summary report with MD/NP and entering the medication in the PCC. The nurse validated how to enter medication into PCC, completed on [DATE REDACTED].

A record review of the facility's training revealed that the DON sent all staff training via Care Feed(electronic training system via telephone) on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 676153 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 676153 B. Wing 01/13/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 Record review of the facility's oxygen monitoring log revealed that the DON started monitoring on [DATE REDACTED] and would be monitored 1 - 7 days/week for 1 - 2 months. Level of Harm - Immediate jeopardy to resident health or Record review of the facility's clinical meeting dated [DATE REDACTED] revealed daily oxygen review for nurse safety managers, administrators, and physical therapists would be present during morning meetings, residents on oxygen would be reviewed daily. A copy of this report will be given to the therapy representative at this time. Residents Affected - Some

Record review of the facility training dated from [DATE REDACTED] - [DATE REDACTED] on Kardex( quick reference to resident care) for all the nursing team revealed how to assess the care provided to the resident, how many staff, and equipment needed during care.

Record review of the facility plan of removal training dated from [DATE REDACTED] - [DATE REDACTED] revealed the nurses had skills check off on change in condition for oxygen, and any general change in condition.

Record review of the facility plan of removal revealed the facility had started monitoring on [DATE REDACTED].

During interviews conducted on [DATE REDACTED] between 9:31 a.m. and 2:31 p.m., with staff on shifts (4 CNAs: CNA A, CNA B, CNA D, and CNA E from 6:00 a.m. -to 2:00 p.m. and 4 LVN: LVN C, LVN D, LVN M, and LVN T from 6:00 a.m. -6:00 p.m.) to verify the in-services were conducted and to validate the staff understanding of

the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident.

During a telephone interview on [DATE REDACTED] between 10:48 a.m. and 11:28 a.m., OT and PTA said the DON texted in service on change in condition of any resident during physical therapy. The OT or PTA would fill out stop and watch and sign the form, then give a copy to the nurse and the second copy to the DON. They said

the DON called them on the phone and conducted the in-service. She said the physical therapist must report any change in condition, including the resident on oxygen, and the physical director had to attend morning meetings.

During interviews conducted on [DATE REDACTED] between 7:45 a.m., and 8:43 p.m., with staff on shifts (4 CNAs: CNAF, CNA G, CNA H, and CNA I from 2:00 p.m. -10:00 p.m., 3 CNAs: CNA J, CNA K, and CNA L from 6:00 p.m. - 6: 00a.m., and 3 LVN: LVN E, LVN F, and LVN G from 6:00p.m. -6 :00 a.m.) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding the knowledge of verification of admission medication from the discharged facility with the physician. They said any order given by the physician should be entered into the computer, and the nurse managers would follow up with chart checks and clarification of any discrepancies. The LVNs and CNAs said the DON conducted in-service on any change in condition would be reported immediately, and the staff should transport residents on oxygen with their concentrator or oxygen tank. The LVNs and CNAs said they had a skills check-off on Kardex on how to assess how much staff and equipment are needed for resident care when providing care to any resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 676153 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 676153 B. Wing 01/13/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 During an interview on [DATE REDACTED] at 1:45 p.m., ADON L said the corporate nurse did an in-service for the nurse manager and the administrator. ADON L said the in-service and skills checkoff included change in condition, Level of Harm - Immediate care plans, medication verification, and chart check after admission; Kardex and oxygen were part of the jeopardy to resident health or change in condition. safety

During an interview on [DATE REDACTED] at 1:57 p.m., the DON, corporate, and administrator were in the room. The Residents Affected - Some DON said she had training from the corporate nurse on change in condition, oxygen, admission process, and

the physical therapy director would come to the meetings. The DON said she would monitor the skills check-off and in-service progress for 1 to 7 days for 2 months.

During an interview on [DATE REDACTED] at 2:0 p.m., the Corporate Nurse said she conducted an in-service for the nurse managers, which included the administrator on verification of new resident medication with the physician, and any new order given by the physician would be entered into the computer by the admitting nurse. The Corporate Nurse said the nurse manager would verify the orders in the computer, cross-check them with the admitting orders, and verify from the nurse whether the physician gave an additional order on admission and if the nurse entered the order in the computer. The Corporate Nurse said residents on oxygen were transferred with portable oxygen when they were not in the room. The Corporate Nurse said staff should report immediately when there was any change in condition, including shortness of breath. The Corporate Nurse said she validated the aide's competencies on Kardex. She also said she reviewed the removal plan with the administrator, DON, and the [NAME] President of operation.

During an interview on [DATE REDACTED] at 2:03 p.m., the Administrator said the Corporate Nurse trained her and the nurse managers on verification of order from the discharged summary report from the transferring facility.

The Administrator said the admitting nurse should verify the order with the physician upon admission and enter the order accurately into the computer. She also said if the nurse received any order, such as an oxygen order, the nurse should enter the order accurately in the computer. The Administrator said the next nurse would also check the order, and the ADON would do a chart check and ensure the admitting nurse entered all the orders correctly into the computer. The Administrator said she was also trained on Kardex and change in condition. The Administrator said the DON would give the names of residents on oxygen to

the therapy director so that they could communicate if any of those residents had shortness of breath to the floor nurse and the DON. The Administrator said the nurse manager would monitor the progress of the training for the next two months.

During an interview on [DATE REDACTED] at 2:10 p.m., the Administrator said the error in the system happened when

the physician gave an oxygen order for CR #1 and LVN H did not put the order in the computer. The Administrator said that ADON J did not completely check the chart because she did not realize CR #1 was supposed to be on oxygen.

During an interview on [DATE REDACTED] at 2:13 p.m., the DON said the system broke when the LVN H missed entering the oxygen order in the computer, and ADON J, who did the chart check, did not realize LVN H did not enter the oxygen order in the computer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 676153 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 676153 B. Wing 01/13/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 An IJ was identified on [DATE REDACTED]. The IJ template was provided to the facility on [DATE REDACTED] at 7:11 p.m. While the IJ was removed on [DATE REDACTED], the facility remained out of compliance at a severity of no actual harm with Level of Harm - Immediate potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated because all jeopardy to resident health or staff had not been trained on the process of medication reconciliation from the discharged facility with the safety physician during admission. The admitting nurse would enter the orders in PCC, and the nurse manager would conduct chart audits to validate accurate orders were entered into the computer using the discharge Residents Affected - Some summary in collaboration with the admitting physician in the community. All staff trained on how to pull up residents' care information from the Kardex, and change in condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 676153 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 676153 B. Wing 01/13/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36918

Residents Affected - Few Based on interviews and record review, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for one of 5 residents (CR #1) reviewed for food and nutrition services.

The facility failed to ensure CR#1's diet order was transcribed and administered as ordered by the physician for a cardiac (2 GM sodium, low fat, low cholesterol) diet.

This failure put residents at risk for health complications related to nonadherence to diet order.

Findings included:

Record review of CR#1's face sheet dated [DATE REDACTED]revealed a [AGE] year-old male was admitted to the facility

on [DATE REDACTED]. CR#1 had diagnoses included: heart failure, (heart cannot pulp enough blood and oxygen to the body's organ), morbid obesity (body mass index greater than 35 combined with other health issues) diabetes mellites (body does not manage blood sugar properly), and atrial fibrillation (irregular heartbeat).

Record review of CR #1's admission MDS assessment dated [DATE REDACTED] revealed CR #1 had BIMS score of 15 out of 15 which indicated intact cognition. Further review revealed CR #1 needed moderate assistance with mobility.

Record review of CR #1's care plan dated [DATE REDACTED] revealed CR #1 resident was at risk for shortness of breath. Intervention: alert my nurse for concentrator and/oxygen tank needs to be changed, provide oxygen as ordered by physician, further review revealed resident had a self-care deficit. Interventions: mobility: I use

a wheelchair, transfer: gait belt X2 team member. It also revealed admission/readmission care plan: I may be at risk for nutritional/hydration concerns. Interventions: nutrition/hydration within prescribed diet.

Record review of CR #1's order summary report dated [DATE REDACTED] read in part . regular diet texture, thin/regular related to acute on chronic heart failure .

Record review of diet order on the communication slip dated [DATE REDACTED] revealed no added salt, cardiac with regular texture.

Record review of CR#1's discharge summary report from the hospital dated [DATE REDACTED] read diet instructions: cardiac (2 GM sodium, low fat, low cholesterol) diet texture: regular.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 676153 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 676153 B. Wing 01/13/2025

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

The Heights of League City 2620 W Walker League City, TX 77573

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 0808 During an interview on [DATE REDACTED] at 1:40 p.m., the DON said CR #1 was on a regular diet, and she spoke to the Dietary manager. The DON said she transcribed the order in the kitchen computer as regular because that Level of Harm - Minimal harm or was what she saw in CR #1's order. The DON said LVN H wrote the diet order on the communication slip potential for actual harm and could not remember if she had clarified the order with the physician. The DON said LVN H wrote no sodium, cardiac diet, and regular texture from the discharge summary report from the hospital. The DON Residents Affected - Few said the Dietary Manager should have verified the order with her since she had a diet communication slip that read cardiac, no sodium, cardiac diet. The DON said she would have verified with CR #1 physician.

During an interview on [DATE REDACTED] at 5:27 p.m., LVN H said she wrote on CR #1 the diet communication slip: No sodium cardiac diet with regular texture. LVN H said she sent the communication slip to the kitchen but transcribed it incorrectly in the computer because she input a regular diet. LVN H said if CR #1 was not provided with the cardiac diet, it could cause CR #1's health condition to worsen. LVN H said she had a skill check-off on the new admission process, and the nurse managers should have checked the new admission paperwork the day after admission.

During an interview on [DATE REDACTED] at 10:57 a.m., the ADON said LVN H did not transcribe the correct order in

the computer for CR #1. The ADON said CR #1 was given the wrong diet until he expired in the facility. The ADON said administering a different diet from what the physician said could cause life-threatening emergencies or death for CR #1. The ADON said LVN H, who admitted CR #1, should have verified the order with the physician and entered the correct order in the computer. Then, the nurse managers should have verified the CR #1's the next day, but the mistake was not caught in time. The ADON said she was not sure if the nursing staff were provided any in-service on the admission process after this incident, but the nursing staff was provided an in-service on the admission process before the incident.

During an interview on [DATE REDACTED] at 1:05 p.m., the Dietary Manager said nursing staff would write a diet communication form and send it to the kitchen. The Dietary Manager said she would cross-check the order

on the slip with the physician's order on the computer. The Dietary Manager said she input a regular diet for

the meal ticket because the physician's order on the computer was regular. The Dietary Manager said she could not remember what the diet communication read. The Dietary Manager said a regular diet could affect CR #1's medical health because he was not provided with a 2gm sodium cardiac diet. The Dietary Manager said she made a mistake, but now she takes the meal communication slip to the morning meeting and checks the order with the DON. The Dietary Manager said, if there were any differences, then the DON would call the physician for clarification.

During an interview on [DATE REDACTED] at 2:58 p.m., the Administrator said LVN H should have gone through the discharge order from the hospital for CR #1, written the diet order on the communication sheet, and given the slip to the kitchen. The Administrator said the Dietary Manager should also check the order on the computer.

The Administrator said the dietary manager should have consulted with the nursing staff to see if there was a discrepancy when she checked the order. The Administrator CR #1 health would be at risk if CR #1 were given the wrong diet.

Record review of the facility undated policy on therapeutic diets read in part . residents receive and consume foods and fluids in the appropriate form and appropriate nutritive content as prescribed .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 676153