Health inspection·May 18, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Residents #113) reviewed for care plans. -Resident #113 did not have a care plan addressing his use of smokeless tobacco. This failure could affect the resident by placing him at risk of not receiving individualized care and services to meet his specific needs. The findings include: Record review of Resident #113's admission Record dated 5/16/2023 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included: cerebral infarction (a stroke), unspecified sequelae of unspecified cerebrovascular disease (residual effects or conditions produced after the acute phase of an illness or injury has ended), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), dysphagia (swallowing difficulties), polyneuropathy (he simultaneous malfunction of many peripheral nerves throughout the body), type 2 diabetes mellitus (a chronic disease characterized by high levels of sugar in the blood), need for assistance with personal care, and dysarthria (speech difficulties due to muscle weakness) following cerebral infarction (stroke). Record review of Resident #113's admission MDS dated [DATE] with an ARD of 4/24/2023 revealed a BIMS of 13 out of 15 indicating minimal cognitive impairment. He required limited to extensive assistance from one or two caregivers with bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. He was frequently incontinent of bladder and bowel but was not on a toileting program. The MDS noted he held food in his mouth and/or cheeks after meals. His diet was mechanically altered and used a feeding tube for 25% or less of his food and 500 cc's or less of fluids. Resident #113 received speech, occupational, and physical therapies, and did not use tobacco products. Record review of Resident #113's Care Plan dated 4/28/2023 revealed a focus on his ADL decline with interventions including assistance with bathing, mobility, dressing, personal hygiene, toileting, transfers, and requiring one staff to assist him with eating. A focus was on his noncompliance with diet and included interventions including of medication administration, education of the importance of adhering to the diet. Resident #113's feeding tube was removed on 4/26/2023 in spite of a swallowing problem related to food hoarding in his mouth with interventions including staff education Page 1 of 17 455876 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few related to dietary and safety needs, staff to check his mouth following each meal, instructing Resident #113 to sit upright when eating, eat slowly, and chew each bite thoroughly, keeping his head at a 45° during meals and thirty minutes after, staff monitoring for choking signs or symptoms, and a referral to speech therapy. The care plan did not address Resident #113's smokeless tobacco use. Record review of Resident #113's speech therapy referral revealed a change to a mechanical soft diet dated 4/19/2023. The referral documented effective swallowing techniques, a seating requirement for any intake by mouth during and 45 minutes after noting the resident is at risk for aspiration, and the physicians review of the recommendations dated 4/19/2023. The physician's review revealed Resident #113 was at risk for life limiting or threatening dysphagia with feeding difficulties, risk of aspiration, and risk of silent aspiration. The Conclusion revealed a high risk for aspiration pneumonia, and a severe overall dysphagia. The recommendations revealed a mechanical soft diet, monitoring pulmonary status, and skilled a dysphagia feeding, exercise, and/or management plan. Observation on 5/16/2023 at 9:35 of Resident #113 revealed he had two cans of smokeless tobacco and spit refuse in a cup with paper towels from smokeless tobacco use on his bedside table. Interview on 5/17/2023 at 8:48 AM with Resident #113 he said he had used his smokeless tobacco since he had been admitted and it was not a new practice. \ He said the facility was aware he had the smokeless tobacco in his room, and he used the smokeless tobacco in the facility. Observation on 5/17/2023 at 8:48 AM of Resident #113 revealed had two cans of smokeless tobacco on his bedside table. The spit refuse cup was no longer on the table and was not observed in the room. Interview on 5/17/2023 at 10:42 AM with Resident #113 he said his family member emptied his spit refuse cup or CNA A would do it. Interview on 5/17/2023 at 10:58 AM with CNA A, she said she was assigned as the CNA for Resident #113. CNA A said she was aware he used smokeless tobacco. CNA A said she had placed a disposable cup in Resident #113's room to use as a spit refuse container, and she would throw the cup away after Resident #113 used it. Interview on 5/17/2023 at 11:24 AM with LVN A, he said he was the assigned nurse to Resident #113. LVN A said this was the second or third time Resident #113 had been admitted to the facility. LVN A said he was unaware of Resident #113 using smokeless tobacco. Interview on 5/18/2023 at 8:55 AM with MDS A and MDS B both said the facility policy for care plan creation required the care plan to be created after the MDS assessment was completed and was based on the MDS and the IDT recommendations. MDS B said the MDS team was not solely responsible for creation of a care plan. MDS A said smokeless tobacco may not be noted on an admission MDS if the resident was cognitive because it was based on the resident's responses. MDS A said the residents were asked if he/she/they had used tobacco in the seven days prior to the creation of the MDS and if the resident denied it then it would not be identified. MDS A said if it was determined a resident did use tobacco after the MDS was created the use should be noted as a focus on the care plan. Interview on 5/18/2023 at 12:17 PM the Admin said he had been the Administrator for approximately six months. He said he was unaware Resident #113 used smokeless tobacco until the survey team was onsite. The Admin said he was unsure why the Nursing Assistants had not provided information to the 455876 Page 2 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurses about Resident #113's smokeless tobacco use. The Admin said Resident #113 denied use of tobacco when he was asked by the MDS Nurse. The Admin said he did not know how Resident #113's use of smokeless tobacco use was not noticed since he had been admitted to the facility. Interview on 5/18/2023 at 12:58 PM with the DON she said the facility creates a baseline care plan for each resident within 24 hours of admission, and a full care plan is created after the MDS was completed. The DON said the care plan was created in utilizing an interdisciplinary team approach and were updated with MDS reviews and any known changes. The DON said smokeless tobacco use by a resident would be addressed in the care plan. The DON said if a Nurse was aware a resident was using smokeless tobacco, the Nurse would be responsible for informing the staff responsible for updating the care plans. The DON said if a CNA was aware a resident was using smokeless tobacco, they should inform the Nurse. The DON said when the facility became aware of a resident using smokeless tobacco, the facility would address it with the resident. Record review of the facility's undated MDS Policy read The Woodlands Nursing and Rehabilitation utilizes the RAI Manual for the MDS policy. Record review of the facility's Comprehensive Care Plans policy dated 10/24/2022 revealed a policy statement which read in part .to develop and implement a comprehensive person-centered care plan for each resident . The policy's explanation and compliance guidelines read in part .will include an assessment of the resident's strengths and needs ., .will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered ., and .will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . 455876 Page 3 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 25 residents (Residents #86) reviewed for pharmacy services. The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered to Resident #86 as ordered by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings include: Record review of Resident #86's admission face sheet, undated, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: hypotension ( low blood pressure), hypertension (elevated blood pressure), atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease (CAD) related to plague buildup in arteries), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), heart failure ( heart not pumping blood as well as it should), respiratory failure, Percutaneous Endoscopic Gastrostomy (PEG) ( a flexible feeding tube placed through the abdominal wall to allow nutrition, fluids and medications to be put directly into the stomach). Record review of Resident #86's Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was not scored. The resident's cognitive skills for daily decision making was scored as three which indicted the resident's mental state was severely impaired. The resident required extensive assistance of two staff for his bed mobility, transfers, dressing, toilet use. The MDS identified an active diagnosis of hypertension, hypotension and medically complex conditions. Record review of Resident #86's care plan updated 05/14/2023 revealed: Focus: Resident #86 had a diagnosis of hypertension and was at risk for fluctuations in blood pressure; Goal: Resident will remain free of signs and symptoms complications of hypertension; Interventions: Give antihypertensive medications as ordered. Record review of Resident #86's care plan updated 05/14/2023 revealed: Focus: Resident #86 had coronary artery disease related to hypertension; Goal: The resident will be free from signs and symptoms of complications of cardiac problems; Interventions: Monitor BP. Notify physician of any abnormal readings 455876 Page 4 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #86's Physician Orders, dated 05/17/2023, revealed, Midodrine 10 mg. Give one tablet by PEG every eight hours for hypotension. Hold for systolic blood pressure (SBP) (the top blood pressure number which measures the pressure in the arteries when the heart beats) greater than 120. Order start dated 11/16/2022. Record review of Resident #86's April 2023 Medication Administration Record (MAR) revealed, the resident was administered Midodrine 10 mg outside of physician set parameter of SBP over 120 on: 04/01/2023 at 8:00 AM with BP 122/67 and at 4:00 PM with BP 125/71 by LVN B 04/02/2023 at 4:00 PM with BP 123/69 by LVN B 04/03/2023 at 4:00 AM with BP 123/69 by LVN B 04/05/2023 at 4:00 AM with BP 122/78 by LVN A 04/06/2023 at 8:00 AM with BP 121/71 and at 4:00 PM with BP 125/69 by LVN B 04/12/2023 at 4:00 PM with BP 123/69 by LVN B 04/15/2023 at 4:00 PM with BP 123/71 by LVN B 04/16/2023 at 8:00 AM with BP 127/61 by LVN B 04/17/2023 at 8:00 AM with BP 123/74 by LVN B 04/20/2023 at 8:00 AM with BP 123/71 by LVN B 04/21/2023 at 4:00 PM with BP 127/68 by LVN B 04/22/2023 at 8:00 AM with BP 122/79 and at 4:00PM 131/63 by LVN B 04/26/2023 at 8:00 AM with BP 123/71 by LVN B 04/29/2023 at 8:00 AM with BP 125/75 by LVN B 04/30/2023 at 8:00 AM with BP 123/69 by LVN B Record review of Resident #86's May 2023 MAR revealed, the resident was administered Midodrine 10 mg outside of physician set parameter of SBP over 120 on: 05/01/2023 at 8:00 AM with BP 124/69 and at 4:00 PM with BP 127/71 by LVN B 05/09/2023 at 4:00 PM with BP 123/65 by LVN B 05/10/2023 at 4:00 PM with BP 123/74 by LVN B 05/11/2023 at 8:00 AM with BP 125/74 by LVN C 455876 Page 5 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0755 05/13/2023 at 8:00 AM with BP 121/63 by LVN B Level of Harm - Minimal harm or potential for actual harm 05/15/2023 at 4:00 PM with BP 121/71 by LVN B Residents Affected - Some In an interview and record review of Resident #86's MAR on 05/17/2023 at 1:30 PM LVN A stated on 04/05/2023 at 4:00 PM Resident #86's Midodrine was checked and initialed it was given by her. LVN A stated she checks the resident's BP prior to administering. LVN A stated if the resident's BP was outside the ordered parameter she would not administer it. The LVN stated Resident #86's BP was outside the parameter the Midodrine should not have been given. LVN A stated maybe she documented incorrectly. LVN A stated she would not give medication that should not be given. LVN A stated the risk of giving this medication was the resident's BP could go too high. It could cause the resident to have a stroke. LVN A stated to prevent this from occurring again she would double check prior to documenting. In an interview and record review of Resident #86's MAR on 05/17/2023 at 1:55PM LVN C stated on 05/11/2023 at 8:00 AM Resident #86's SBP was 125. LVN C stated the MAR was checked and initialed by him which documented the Midodrine was administered by him. LVN C stated he checks the resident's BP and orders for parameters before giving. The LVN stated he may have documented incorrectly. The medication should not have been given. The resident's BP was too high. The risk was the resident's BP could elevate too high. To prevent this again LVN C stated he would pay more attention to the documentation. In an interview and record review of Resident #86's MAR on 05/18/2023 at 9:03AM LVN B stated it was his initials and check on the MAR which indicated he did give the Midodrine. LVN B stated he felt terrible about giving the medication. LVN B stated the parameters were to hold the medication for SBP greater than 120. LVN B stated he read the order incorrectly. The medication should not have been given. LVN B stated the medication could cause the resident's BP to get too high. LVN B stated he had been in-serviced on medication administration regarding following the physician's orders and the resident's rights. Observation on 05/18/2023 at 9:24 AM revealed Resident #86 in bed on his left side with the head of his bed elevated. Resident #86 had oxygen by tracheostomy. The resident's tube feeding was turned off. Resident #86 was nonverbal. In an Interview on 05/18/2023 at 10:18 AM the DON stated she identified the issue with Midodrine for Resident #86. The medication was given outside the ordered parameters. The DON stated the check mark on the MAR indicted the medication was given. The initials indicated which nurse administered the medication. The DON stated her expectation was the medication was given as ordered by the physician. This medication was given to treat low blood pressure. The DON stated the risk was it could cause the resident's BP could go to high. The staff have been inserviced on medication administration. Inservices included following the physician's orders, following the resident rights for medication administration . The DON stated to prevent this from occurring again we would provide inservices on this medication the risk and the importance of reading the order correctly. In an interview on 05/18/2023 at 10:54 AM the Administrator stated he expected the physician's orders were followed during medication administration. The Administrator stated there was an issue concerning this medication being administered outside the ordered parameters. The risk to the resident was the BP could increase too much. To prevent this we need to educate. 455876 Page 6 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0755 Level of Harm - Minimal harm or potential for actual harm In a phone interview on 05/18/2023 at 1:35 PM the facility's pharmacy consultant stated Midodrine was a medication used to treat hypotension. The purpose was to raise a resident's blood pressure. She continued and stated the physician ordered parameters to hold the medication because it should not be given if the blood pressure was already high enough. The risk of giving the medication was the blood pressure could elevate too much. Residents Affected - Some In an interview on 05/18/2023 at 4:00 PM the Administrator stated the nurses monitor medication administration. The charge nurse monitors the MARS to make sure the medications were administered correctly. Record review of the facility policy titled Medication Administration revised, 10/01/2019, revealed, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . Procedures: 2. Administration Medications are administered in accordance with written orders of the prescriber . 455876 Page 7 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 23% based on 8 errors out of 34 opportunities, which involved 4 of 11 (Residents #120, #1, #4 and #72) residents reviewed for medication errors. Residents Affected - Some 1.MA A administered the wrong dose of Hydralazine and Losartan (two blood pressure medications used to lower blood pressure) to Resident #120. She also administered Sennosides instead of Sennosides with Docusate (a medication used to treat constipation), Ferrous sulfate instead of Ferrous Gluconate (an iron supplement) and did not administer Finasteride to Resident #120 (a medication used to shrink an enlarged prostate) as ordered by the Physician. 2.MA B administered the wrong dose of Miralax to Resident #1. 3.MA C administered the wrong dose of Flonase to Resident #4. 4.MA D administered Sennosides to Resident #72 instead of Sennosides with Docusate as ordered by the Physician. These failures could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications. Findings included: 1.Record review of Resident #120's face sheet revealed a [AGE] year-old male readmitted to the facility on [DATE]. His diagnosis included atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall), hypertension (high blood pressure), benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland), and constipation. Record review of Resident #120's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. He required supervision of one person for ADL care. Record review of Resident #120's undated care plan revealed he had hypertension and was at risk for fluctuations in blood pressure readings. His interventions were to give anti-hypertensive medications as ordered. He had coronary artery disease related to hypertension. His intervention was to give all cardiac medications as ordered by the physician. Record review of Resident #120's Physician Order Report for May 2023 revealed the following orders: Hydralazine 50 mg give 2 tablets by mouth every 8 hours for hypertension, order date 5/17/23, Losartan potassium 50 mg give 2 tablets by mouth one time a day for hypertension, order date 5/17/23, Finasteride 5 mg give 1 tablet by mouth one time a day for prostate, order date 5/17/23, 455876 Page 8 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0759 Level of Harm - Minimal harm or potential for actual harm Ferrous Gluconate 324 mg (38 FE) give 1 tablet by mouth one time a day for supplementation, order date 5/17/23, Sennosides-Docusate 8.6-50 mg give 1 tablet by mouth two times a day for constipation, order date 5/17/23. Residents Affected - Some In an observation on 5/18/23 at 9:13 a.m. MA A checked Resident #120's blood pressure which was 130 (SBP) / 65 (DBP) and the heart rate was 75. She prepared Ferrous sulfate 325 mg (65 FE) - 1 tablet, Sennosides 8.6 mg (without docusate 50 mg) - 1 tablet, metformin 500 mg - 1 tablet, Sertraline 100 mg - 1 tablet, Ciprofloxacin 500 mg - 1 tablet, Gabapentin 100 mg - 1 tablet, chewable Aspirin 81 mg - 1 tablet, Acidophilus - 1 tablet, Magnesium oxide 400 mg - 1 tablet, and Amlodipine 10 mg 1 tablet. MA showed this Surveyor the medication blister pack for Finasteride 5 mg but did not place a tablet in the medication cup. MA A said there were 10 tablets in the medication cup and 10 tablets were observed in the medication cup. MA entered the room and administered the medication to Resident #120. In an observation and interview on 5/18/23 at 9:48 a.m. MA A signed off the medications on the computer, including the Finasteride, to indicate they were administered to Resident #120. Upon medication reconciliation with this Surveyor, MA A reviewed Resident #120's eMAR and said she was supposed to administer 11 tablets but said she only prepared and administered 10 tablets. MA A said she was unsure what medication was missed. MA A removed the blister packs and said the Finasteride was missed because the blister was full and there were no pills removed. MA A placed a Finasteride tablet into the medication cup. Continued observation at 9:54 a.m. revealed LVN D gave MA A Losartan and Hydralazine tablets that were retrieved from the emergency medication kit. MA A prepared Losartan 25 mg - 2 tablets, and Hydralazine 25 mg - 2 tablets for Resident #120. MA A said she would give 2 tablets of each medication according to the Physician orders. MA A administered the blood pressure medication and Finasteride to Resident #120. In an observation and interview on 5/18/23 at 9:56 a.m., MA A signed the medications on the computer to indicate they were administered. She said each Hydralazine tablet was 25 mg and two 25 mg tablets would equal 50 mg. She said she was supposed to administer two of the 50 mg tablets because the Physician's order was written for a total of 100 mg. She said it was the same mistake for Losartan. The Losartan tablet was 25 mg and two were administered to equal 50 mg. Resident #120's Physician order for Losartan was two 50 mg tablets for a total of 100 mg. She said she was overwhelmed when she prepared the resident's medication because some of his medications were not available. She said both Losartan and Hydralazine were used for hypertension (high blood pressure) and the resident did not receive the full prescribed dose. She said she was trained to verify the right dose, time and name when she administered medication. In an interview on 5/18/23 at 10:03 a.m., MA A said she was supposed to administer Sennosides 8.6 mg 50 mg. to Resident #120 instead of Sennosides 8.6 without the Docusate 50 mg. She said the medication strength on the bottle could be used to ensure accuracy. She said the medication was used for constipation and the resident could be at risk of receiving a lower, less effective dose. She said she should have looked at the dose very well when she prepared the medication and said it was a medication error. MA A said she administered Ferrous sulfate to Resident #120 which was not the same as Ferrous gluconate. She said Ferrous gluconate was available on the cart, but said she only read the Ferrous portion of the Physician's order. She said she should have looked at the order very well. MA A said she was trained monthly on medication administration which included verifying the right patient, dosage, time, and documentation. 455876 Page 9 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0759 Level of Harm - Minimal harm or potential for actual harm In an interview on 5/18/23 at 11:34 a.m., LVN D said MA A told her Resident #120 needed Losartan 50 mg and Hydralazine 50 mg but did not say the quantity. She said the emergency medication kit only contained 25 mg of Losartan and Hydralazine. She said she pulled the medication from the emergency kit and handed the medication to MA A. She said she did not conduct a verbal exchange and said it was her mistake. Residents Affected - Some In an interview on 5/18/23 at 3:30 p.m., the DON said she expected medication aides and nurses to verify the right dose, time, route, and resident on the eMAR when administering medication. She said she expected nursing staff to administer medications according to physician orders because that was the standard of care. The DON said she expected MA A to administer Ferrous gluconate to Resident #120 as ordered by the Physician. She said Ferrous gluconate and Ferrous sulfate were different medications and it was considered a medication error if not given per physician orders. She said MA A should have counted her medications and compared them to the eMAR to ensure all medications were given, including the Finasteride. She said the nurse, LVN D, should have verified the Physician's order when she removed the blood pressure medications from the emergency kit. She said MA A was responsible to check the medications against the Physician orders for accuracy. She said the blood pressure medications were used for hypertension and the resident could be at risk of not receiving the desired effect of the medication which was to control his blood pressure. 2. Record review of Resident #1's face sheet revealed a [AGE] year-old female readmitted on [DATE]. Her diagnoses included constipation, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anxiety (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), and hypertension. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. She required extensive assistance of 1-2 staff for transfers, dressing, eating, toilet use, and personal hygiene. Record review of Resident #1's undated care plan revealed she had constipation. Her interventions were to administer bowel medications as ordered. Record review of Resident #1's Physician Orders for May 2023 revealed an order for Miralax packet 17 gm give 1 packet by mouth two times a day for constipation, order date 7/18/21. In an observation and interview on 5/17/23 at 3:36 p.m., MA B retrieved Clearlax 3350 from the medication cart for Resident #1. MA B removed the top and pointed to a line that was well below the 17-gm line marked inside of the medication cap. MA B poured approximately 9 grams of Clearlax powder into the medication cup. The 17 gm line was still visible. MA B mixed the Clearlax with water and administered it to Resident #1. In an interview on 5/17/23 at 3:46 p.m. MA B said she thought the 17-gram mark was at the middle line and did not realize the arrow pointed up to the top of the medication cup. She said this Surveyor was the first person who told her that. She said the powder should be at the top of the white line. She said the MAR told her how much Clearlax to administer. She said Clearlax was used for a stool softener and said Resident #1 received a little less because she did not fill it to the 17-gram line. In an interview on 5/18/23 at 3:30 p.m., the DON said Miralax should be used as directed and the powder should be poured to the 17-gram line. She said Miralax was a laxative and said Resident #1 455876 Page 10 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0759 could be at risk of constipation or could not receive the desired effect of the prescribed medication. Level of Harm - Minimal harm or potential for actual harm 3. Record review of Resident #4's face sheet revealed a [AGE] year-old male readmitted to the facility on [DATE]. His diagnoses included dementia, respiratory failure (a syndrome in which the respiratory system fails in one or both of its gas exchange functions: oxygenation and carbon dioxide elimination), and acute kidney failure (a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days). Residents Affected - Some Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. He required extensive assistance of one staff for ADL care. Record review of Resident #4's Physician Orders for May 2023 revealed an order for Flonase allergy relief nasal suspension 50 mcg/act 1 spray in both nostrils two times a day for seasonal allergies, order dated 4/19/23. In an observation and interview on 5/16/23 at 4:11 p.m., MA C prepared Fluticasone 50 mcg for Resident #4. She entered the resident's room and administered one spray of Fluticasone 50 mcg in each nostril. She then asked Resident #4 if he wanted another spray in each nostril. MA C administered an additional spray in each nostril for a total of 2 sprays in each nostril. MA C said Resident #4 sometimes wants two sprays in each nostril instead of one and will say one spray does not help him. She said she previously notified the nurse that the physician's order should be for one or two sprays. She said the current Physician's order, which was written next to the dispensed supply on the eMAR, was two sprays in each nostril. She said the one spray per each nostril that was also written on the eMAR above the dispensed supply was when it was first ordered on an unknown date. She said she always asked the resident if he wanted one or two sprays in each nostril for his seasonal allergies. In an interview on 5/18/23 at 3:30 p.m., the DON said the Physician's order for Resident #4's Flonase was 1 spray in each nostril. She said there should have been a change in dose sticker placed on the medication bottle. She said she expected nursing staff to follow the Physician's order. 4. Record review of Resident #72's face sheet revealed a [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses included constipation and Alzheimer's Disease. Record review of Resident #72's annual MDS assessment dated [DATE] revealed a staff assessment for mental status score of 3 which indicated severely impairment. She required extensive assistance of one staff for personal hygiene, toilet use, dressing, bed mobility, and transfers. Record review of Resident #72's Physician Orders for May 2023 revealed an order for Senna-Docusate 8.6-50 mg give 1 tablet by mouth two times a day for constipation, order date 2/26/21. In an observation and interview on 5/17/23 at 3:09 p.m., MA D administered Senna 8.6 mg (without docusate) - 1 tablet to Resident #72. She said she did not give the Senna - S (with Docusate sodium 50 mg) to Resident #72 because it contained other ingredients such as natural vegetable, laxative, stool softener, and docusate sodium 50 mg which she did not see on the MAR. She said she was trained to only use Senna unless the MAR specified the extra ingredients. MA D said Resident #72's physician order was written for Senna 8.6 mg and Docusate 50 mg. She said the medication she administered did not have Docusate 50 mg, just the Sennosides 8.6 mg. She said she should have administered the Senna 455876 Page 11 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some S because it contained both Docusate 50 mg and Sennoside 8.6 mg. MA D said when she administered medications she verified the right patient, medication, dose, and compared the medication to the MAR. She said Senna-Docusate was used for constipation and Senna with docusate would be more powerful because it had two medications. In an interview on 5/18/23 at 3:58 p.m., the Administrator said he expected nursing staff to follow the medication administration rights which included the right dose, medication, and route. He said he expected staff to follow the Physician orders for the resident's health and safety. He said if the Physicians order was not followed an adverse effect could occur or sometimes nothing could happen. Record review of the facility's Medication Administration dated 10/1/19 read in part, .medications are administered as prescribed in accordance with good nursing principles and practices .Procedure: . D. 10 rights of medication administration - 2. Right medication - check the medication supply and compare it to the doctor's orders to make sure it is the right one . 3. Right Dosage - this is one of the most important in the 10 rights of medication administration. Check the doctor's orders/MAR against the medication on hand . 455876 Page 12 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that 1 of 11 residents (Resident #120) was free from significant medication errors. Residents Affected - Few MA A administered the wrong dose of Hydralazine and Losartan (two blood pressure medications used to lower blood pressure) to Resident #120. She also administered Sennosides instead of Sennosides with Docusate, Ferrous sulfate instead of Ferrous Gluconate, and did not administer Finasteride to Resident #120 as ordered by the Physician. Findings included: Record review of Resident #120's face sheet revealed a [AGE] year-old male readmitted to the facility on [DATE]. His diagnoses included atherosclerotic heart disease (a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall), hypertension (high blood pressure), benign prostatic hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland), and constipation. Record review of Resident #120's quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated intact cognition. He required supervision of one person for ADL care. Record review of Resident #120's undated care plan revealed he had hypertension and was at risk for fluctuations in blood pressure readings. His interventions were to give anti-hypertensive medications as ordered. He had coronary artery disease related to hypertension. His intervention was to give all cardiac medications as ordered by the physician. Record review of Resident #120's Physician Order Report for May 2023 revealed the following orders: Hydralazine 50 mg give 2 tablets by mouth every 8 hours for hypertension, order date 5/17/23, Losartan potassium 50 mg give 2 tablets by mouth one time a day for hypertension, order date 5/17/23, Finasteride 5 mg give 1 tablet by mouth one time a day for prostate, order date 5/17/23, Ferrous Gluconate 324 mg (38 FE) give 1 tablet by mouth one time a day for supplementation, order date 5/17/23, Sennosides-Docusate 8.6-50 mg give 1 tablet by mouth two times a day for constipation, order date 5/17/23. In an observation on 5/18/23 at 9:13 a.m. MA A checked Resident #120's blood pressure which was 130 (SBP) / 65 (DBP) and the heart rate was 75. She prepared Ferrous sulfate 325 mg (65 FE) - 1 tablet, Sennosides 8.6 mg (without docusate 50 mg) - 1 tablet, metformin 500 mg - 1 tablet, Sertraline 100 mg - 1 tablet, Ciprofloxacin 500 mg - 1 tablet, Gabapentin 100 mg - 1 tablet, chewable Aspirin 81 mg - 1 tablet, Acidophilus - 1 tablet, Magnesium oxide 400 mg - 1 tablet, and Amlodipine 10 mg 1 tablet. MA showed this Surveyor the medication blister pack for Finasteride 5 mg but did not place a 455876 Page 13 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tablet in the medication cup. MA A said there were 10 tablets in the medication cup and 10 tablets were observed in the medication cup. MA entered the room and administered the medication to Resident #120. In an observation and interview on 5/18/23 at 9:48 a.m. MA A signed off the medications on the computer, including the Finasteride, to indicate they were administered to Resident #120. Upon medication reconciliation with this Surveyor, MA A reviewed Resident #120's eMAR and said she was supposed to administer 11 tablets but said she only prepared and administered 10 tablets. MA A said she was unsure what medication was missed. MA A removed the blister packs and said the Finasteride was missed because the blister was full and there were no pills removed. MA A placed a Finasteride tablet into the medication cup. Continued observation at 9:54 a.m. revealed LVN D gave MA A Losartan and Hydralazine tablets that were retrieved from the emergency medication kit. MA A prepared Losartan 25 mg - 2 tablets, and Hydralazine 25 mg - 2 tablets for Resident #120. MA A said she would give 2 tablets of each medication according to the Physician orders. MA A administered the blood pressure medication and Finasteride to Resident #120. In an observation and interview on 5/18/23 at 9:56 a.m., MA A signed the medications on the computer to indicate they were administered. She said each Hydralazine tablet was 25 mg and two 25 mg tablets would equal 50 mg. She said she was supposed to administer two of the 50 mg tablets because the Physician's order was written for a total of 100 mg. She said it was the same mistake for Losartan. The Losartan tablet was 25 mg and two were administered to equal 50 mg. Resident #120's Physician order for Losartan was two 50 mg tablets for a total of 100 mg. She said she was overwhelmed when she prepared the resident's medication because some of his medications were not available. She said both Losartan and Hydralazine were used for hypertension (high blood pressure) and the resident did not receive the full prescribed dose. She said she was trained to verify the right dose, time and name when she administered medication. In an interview on 5/18/23 at 10:03 a.m., MA A said she was supposed to administer Sennosides 8.6 mg 50 mg. to Resident #120 instead of Sennosides 8.6 without the Docusate 50 mg. She said the medication strength on the bottle could be used to ensure accuracy. She said the medication was used for constipation and the resident could be at risk of receiving a lower, less effective dose. She said she should have looked at the dose very well when she prepared the medication and said it was a medication error. MA A said she administered Ferrous sulfate to Resident #120 which was not the same as Ferrous gluconate. She said Ferrous gluconate was available on the cart, but said she only read the Ferrous portion of the Physician's order. She said she should have looked at the order very well. MA A said she was trained monthly on medication administration which included verifying the right patient, dosage, time, and documentation. In an interview on 5/18/23 at 11:34 a.m., LVN D said MA A told her Resident #120 needed Losartan 50 mg and Hydralazine 50 mg but did not say the quantity. She said the emergency medication kit only contained 25 mg of Losartan and Hydralazine. She said she pulled the medication from the emergency kit and handed the medication to MA A. She said she did not conduct a verbal exchange and said it was her mistake. In an interview on 5/18/23 at 3:30 p.m., the DON said she expected medication aides and nurses to verify the right dose, time, route, and resident on the eMAR when administering medication. She said she expected nursing staff to administer medications according to physician orders because that was the standard of care. The DON said she expected MA A to administer Ferrous gluconate to Resident #120 as ordered by the Physician. She said Ferrous gluconate and Ferrous sulfate were different 455876 Page 14 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications and it was considered a medication error if not given per physician orders. She said MA A should have counted her medications and compared them to the eMAR to ensure all medications were given, including the Finasteride. She said the nurse, LVN D, should have verified the Physician's order when she removed the blood pressure medications from the emergency kit. She said MA A was responsible to check the medications against the Physician orders for accuracy. She said the blood pressure medications were used for hypertension and the resident could be at risk of not receiving the desired effect of the medication which was to control his blood pressure. In an interview on 5/18/23 at 3:58 p.m., the Administrator said he expected nursing staff to follow the medication administration rights which included the right dose, medication, and route. He said he expected staff to follow the Physician orders for the resident's health and safety. He said if the Physicians order was not followed an adverse effect could occur or sometimes nothing could happen. Record review of the facility's Medication Administration dated 10/1/19 read in part, .medications are administered as prescribed in accordance with good nursing principles and practices .Procedure: . D. 10 rights of medication administration - 2. Right medication - check the medication supply and compare it to the doctor's orders to make sure it is the right one . 3. Right Dosage - this is one of the most important in the 10 rights of medication administration. Check the doctor's orders/MAR against the medication on hand . 455876 Page 15 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: Food items were found in the kitchen with expired and beyond the use by date. Potentially hazardous /time control for safety food on the work counter With temperature of 66.5 degrees Fahrenheit. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings include: Observation of the facility's kitchen and interview on 05/16/23 between 9:00 am and 9:45 am with the Dietary Food Service Manager revealed the following: A plastic container of Low-fat Cottage Cheese with an expiry date of 4/21/23 in the walk-in refrigerator. A plastic container of Cherry Pie Filling with a used by date 04/15/23 in the walk-in refrigerator. A plastic container of Mandarin Oranges with a used by date 04/19/23 in the walk-in refrigerator. A plastic container of Chicken Salad with an expiry date of 4/12/23 in the refrigerator. A pan of Pureed Pork with a temperature of 66.5 degrees Fahrenheit on the worktable counter. Interview with the Dietary Food Service Manager on 05/16/23 at 9:00 AM she stated that the dietary staff Should have used or discarded the food prior to the used by date. Record review of facility's Policy on Food Storage dated 05/10/18 Read in part .Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 48 hours or discarded. .potentially hazardous /time control for safety food hot food with a holding temperature of 135 degrees higher or cold food with a holding temperature of 41 degrees or lower. 455876 Page 16 of 17 455876 05/18/2023 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. Residents Affected - Many -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 05-16-23 at 9:20 AM am, with the Food Service Manager revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster and the lid and door were open. Interview on 5-16-23 at 9:20 am, with the Food Service Manager she stated that the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She stated that she is responsible for all requirements be met in the Food Service Department. She will in-service the dietary staff on following the Policy and Procedure for Garbage Disposal. Policy and Procedure of Food Service Department for Garbage Receptacles dated June 1, 2019, read in part .7. Outside dumpsters provided by garbage pick-up services shall have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed. 455876 Page 17 of 17