Health inspection·August 1, 2024

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 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 29 residents (Residents #2) reviewed for pharmacy services. Residents Affected - Few The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered to Resident #2 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 included: Record review of Resident #2's admission face sheet, undated, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included: hypertension (elevated blood pressure), congestive heart failure (a chronic condition in which the heart not pumping blood as well as it should), respiratory failure, Percutaneous Endoscopic Gastrostomy (G-tube) ( a flexible feeding tube placed through the abdominal wall to allow nutrition, fluids and medications to be put directly into the stomach), chronic atrial fibrillation (an irregular rapid heart ratee that causes poor blood flow). Record review of Resident #2's care plan revision updated 06/10/2024 reflected: Problem: Resident #2 had hypertension. Resident #2 was at risk for ineffective peripheral tissue perfusion (passage of fluid through the circulatory system); Goal: Resident will remain free of signs and symptoms of hypertension. Interventions: Give antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a form of low blood pressure) and increased heart rate. Record review of Resident #2's care plan revision updated 06/10/2024 reflected: Focus: Resident #2 had coronary artery disease related to atrial fibrillation. Resident #2 was at risk for decreased cardiac output (heart does not pump enough blood to meet the body needs). Goal: The resident will be free from signs and symptoms of complications of cardiac problems. Page 1 of 10 455876 455876 08/01/2024 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0760 Interventions: Give all cardiac medications as ordered by the physician. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's July 2024 Medication Administration Record (MAR) dated 07/01/2024-7/31/2024 reflected, the resident was administered Midodrine 5 mg outside of physician set parameter of SBP over 130 on: Residents Affected - Few 07/24/2024 at 8:00 AM with BP 139/67 by RN B 07/25/2024 at 8:00 AM with BP 133/62 and at 4:00 PM with BP 133/62 by RN A 07/26/2024 at 4:00 AM with BP 133/64 by RN A Record review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] reflected 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 was dependent on staff for her bed mobility, transfers, and dressing. The MDS identified Resident #2's active diagnosis was medically complex conditions. Record review of Resident #2's Physician Orders, dated 08/01/2024, revealed, Midodrine 5 mg. Give one tablet by G-tube three times a day. Hold for systolic blood pressure (SBP) (the top blood pressure number which measures the pressure in the arteries when the heart beats) greater than 130. Order start dated 07/12/2024. In an interview and record review on 08/01/2024 at 11:50 AM RN A stated he reviewed the physicians orders. RN A stated he checked the resident's blood pressure to assess if the blood pressure was outside of the ordered parameters. At this time RN A reviewed Resident #2's MAR. RN #2 stated the order was not to administer the medication if the resident's SBP was greater than 130. RN A stated the medication should not have been given because the resident's SBP was 133. RN A stated the purpose of the medication was to elevate the residents blood pressure. The RN stated the risk was causing the resident's blood pressure too high. The RN stated he did administer the medication according to the MAR. RN A stated if he had not given the medication, it the MAR would be documented with the number 4 to indicate the medication was held due to being outside ordered parameters. RN A stated he did not know why he gave it. In an interview on 08/01/2024 at 12:10 PM with the Pharmacist she stated Midodrine was to be given for low blood pressure. She stated the hold order for the SBP was to prevent the medication from going too high. The Pharmacist stated when the medication was given over the SBP parameters it was a risk of the blood pressure going too high for the resident. The Pharmacist stated she monitored the MARS monthly, if she found an error, she would bring it to the nurse's attention and sometimes write a recommendation and report it to the DON. Observation on 08/01/2024 at 12:15 PM revealed Resident #2 in bed. Resident #2's head of her bed was elevated with tube feeding (liquid form of food carried through the body) running on a pump. Resident #2 was nonverbal and unable to be interviewed. In a phone interview on 08/01/24 at 12:37 PM the NP caring for Resident #2 stated the parameters to hold for SBP at 130 were ordered from the hospital. She stated the order was continued at the facility. The NP stated the resident had low blood pressure. The NP stated the medication was to elevate the resident's blood pressure. The risk was the blood pressure could get too high. 455876 Page 2 of 10 455876 08/01/2024 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 In an interview and record review on 08/01/24 at 1:04 PM the DON stated her expectations was the medication was administered as ordered by the physician. Midodrine was given to elevate blood pressure. The DON stated the order was to hold when the SBP was over 130. She stated according to the blood pressures the medications were not to be given. The DON reviewed the electronic medication administration record. She stated the medication was documented as administered at those times by RN A and RN B. The DON stated the medication administration was monitor monthly by the ADON, DON and pharmacist. She stated if they identified a problem it was addressed with the staff. In an interview on 08/01/2024 at 1:42 the Administrator stated he was aware the medication was given to elevate low blood pressure. He stated the DON and ADON monitor MARS and physician's orders monthly. We have clinical meetings to discuss identified administration problems. The risk was the medication could cause the resident's blood pressure from going to high. We plan to educate to prevent this again. In an interview and record review on 08/01/2024 at 1:47 PM RN B reviewed Resident #2's MAR. She stated she followed steps to administer medications. She checked the resident's blood pressure. She reviewed the physician order. She stated she did not know why it was administered. She stated it should not have been given. The risk was the resident's blood pressure could go high. RN B stated she will go through the steps more carefully to prevent a mistake. Record review of the facility policy titled Medication Administration Date implemented, 10/24/2022, reflected, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 455876 Page 3 of 10 455876 08/01/2024 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (400 Hall Nurse Medication Cart) of four medication carts reviewed for storage of medications. The Nurse Medication Cart for 400 Hall had torn protective seals on the back of Resident #103's Tramadol HCL 50mg (a narcotic used to treat moderately severe pain) medication blister pill card (a type of medication packaging, with multiple small, sealed compartments that hold individual doses of medication) found in the locked narcotic drawer during review of medication carts. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, infection, and drug diversion. Findings included: Record review of Resident #103's face sheet dated 08/01/2024 reflected an [AGE] year-old female first admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Alzheimer's disease, dementia, depression, anxiety, arthritis, and stroke. Record review of Resident #103's quarterly MDS dated [DATE], reflected she had severely impaired cognitive skills. She required moderate assistance from staff for eating, oral hygiene, and personal hygiene. She was dependent on staff for toileting, showering and dressing. She received scheduled pain medication in the last 5 days. Record review of Resident #103's undated care plan reflected she had interventions for chronic pain that included anticipate the resident's need for pain relief. Record review of Resident #103's active physician orders as of 07/31/2024 reflected an order for Tramadol HCL 50mg, one tablet by mouth every 8 hours as needed for pain scale 5 to 10, start date 10/13/2023. Record review of Resident #103's MAR for July 2024 reflected no administration of Tramadol HCL 50mg as needed for pain scale of 5 to 10. Observation and interview on 07/31/2024 at 11:56 AM revealed the narcotic storage of Resident #103's Tramadol HCL 50mg tablets #4, #8, #11, #13 and #19 out of 29 tablets in the blister pill card, had torn protective seals. The nurse assigned to the nurse cart for 400 Hall was LVN Q. LVN Q stated if the seals were torn, they should never be taped closed, or left in the pack with torn seals. LVN Q stated the reason was that the pills could be replaced by a different tablet, and another reason would be a break in infection control. LVN Q stated all the nurses were responsible to ensure accuracy of the narcotic count and integrity of the drugs. LVN Q explained that when she counts narcotics, she did not necessarily look at the integrity of the package and was surprised that 5 tablets had torn seals. In an interview on 08/01/2024 at 8:20 AM, the DON stated the nurses should be checking the backs of 455876 Page 4 of 10 455876 08/01/2024 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the blister cards to make sure the seals are intact, no tears or holes are present. The DON stated the risks are that the narcotic could be removed and replaced with another pill and due to infection control reasons. The DON stated if 5 tablets were wasted due to torn seals then she would contact the pharmacy to have tablets credited to the resident. Record review of the facility staff in-service training report for Medication Administration dated 07/31/2024 and conducted by staff including the DON reflected in part: .if medications are compromised and/or opened in the blister pack, DO NOT administer those medications. Medications that appear opened or resealed must be wasted with a witness and pharmacy should be notified to credit the resident for the wasted medication . Record review of the facility policy and procedure for Medication Administration, date implemented on 10/24/2022, read in part: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 455876 Page 5 of 10 455876 08/01/2024 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 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 the facility's only kitchen. Residents Affected - Many The facility did not store, prepare, or distribute food in a safe and sanitary manner: Dry storage contained undated food/drink items; Refrigerator contained undated drink items; Freezer contained opened/not sealed food items. These failures could place residents at risk of foodborne illness. Findings included: During an initial tour of the kitchen on 07/30/24 at 8:15 AM, the following food/drink items were found in the dry storage: *9, 14.5oz can of Diced Red Peppers with no expiration date located on can *2pkgs, 24oz of Strawberry Gelatin with no expiration date on the packages *6pkgs, 24oz of Grape Drink Mix with no expiration date on the packages *6pkgs, 24oz of Fruit Punch Drink mix with no expiration date on the packages *2pkgs, 24oz of Pink Lemonade Drink mix with no expiration date on the packages *2pkgs, 24oz of Lemonade Drink mix with no expiration date on the packages *10 packets, .49oz of [NAME] Crackers with no expiration date on the packages During an initial tour of the kitchen on 07/30/24 at 8:48 AM, the following food items were found in the refrigerator: *3pkgs of unknown kind of sandwich meat with no expiration date on the packages During an initial tour of the kitchen on 07/30/24 at 8:54 AM, the following food items were found in the freezer: *Approximately 15 Fish Patties opened/not sealed, with freezer burn *Approximately 75 pieces of Catfish Nuggets opened/not sealed *Approximately 75-100 Turkey Breakfast Sausage Patties opened/not sealed 455876 Page 6 of 10 455876 08/01/2024 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0812 *10lb box of Pork Sausage opened/not sealed Level of Harm - Minimal harm or potential for actual harm *8 slabs of Beef Liver opened/not sealed During a tour of the kitchen on 07/31/24 at 2:34 PM, the following food items were found in the freezer: Residents Affected - Many *Approximately 50 pieces of Turkey Sausage Patties opened/not sealed *5lb bag of Peas/Carrots opened/not sealed Interview on 7/30/24 at 9:11 AM with Dietary Supervisor stated she has worked at facility for a year. She said she did not know when the food items without expiration dates were to expire or needed to be used by. When asked about the Strawberry Gelatin and Drink Mixes, she said I heard they have a 90-day shelf life. The Dietary Supervisor said the storage/label/seal/date policy was when the food was delivered it was supposed to be labeled and put in appropriate area. She also said to ensure all food/drink items are labeled/stored/sealed/dated properly a staff person will be assigned to each area; dry goods, refrigerator, and freezer to make sure all food/drink items are dated, stored and sealed properly, and if any expired items are found they are to be discarded. The Dietary Manager said the risk to residents if they are served food that is expired could cause illness, food poisoning, or even death. Review of facility policy titled Food Storage, dated 12/01/11 reflected .Policy: The consultant dietitian will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe consumption All food will be stored according to the state and Federal Food codes. The following guidelines should be followed. 1. Dry Storage rooms .d. To ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. f. Where possible, items are left in the original cartons placed with the date visible. 2. Refrigerators .a. All refrigerated foods are stored per state and federal guidelines. e. All refrigerated foods are dated, labeled and tightly sealed, including leftovers, using clean, nonabsorbent, covered containers that are approved for food storage. Use all leftovers and refrigerated, ready-to-eat food shall be discarded by their expiration date or within 7 days. Freezers .e. Frozen foods are stored in moisture-proof wrap or containers that are labeled and dated. 455876 Page 7 of 10 455876 08/01/2024 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0880 Provide and implement an infection prevention and control program. 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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #4, #14 and #10) reviewed for infection control. Residents Affected - Some MA S failed to perform hand hygiene between Resident #4, #14 and #10 during medication pass. This failure could place residents at risk for cross contamination, infection and decline in health. Findings included: Record review of Resident #4's face sheet dated 08/01/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and originally admitted on [DATE]. Her diagnoses included Alzheimer's disease, diabetes, resistance to multiple antibiotics, stroke, one sided paralysis following stroke, dementia, hypertension, and malnutrition. Record review of Resident #4's quarterly MDS (a Resident Assessment and Care Screening tool) dated 06/06/2024 reflected a BIMS score of 4 out of 15 indicating severe cognitive impairment. She was dependent on staff for assistance with all ADLs. She had impairment with functional limitation in range of motion to one side of upper and lower extremities. Record review of Resident #4's active physician orders as of 07/31/2024 reflected an order for Carvedilol tablet 6.25mg, give 1 tablet by mouth two times a day for Hypertension, hold for BP less than 110/50, order date was 03/06/24. Record review of Resident #4's MAR for July 2024 reflected Carvedilol 6.25mg was administered on 07/31/2024 at 4:00 PM by MA S. Resident #4's vital signs were documented as BP 122/54 and pulse of 67. Record review of Resident #14's face sheet dated 07/31/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnoses included diabetes, heart failure, HTN, heart disease, chronic pain and chronic kidney disease. Record review of Resident #14's quarterly MDS dated [DATE] reflected a BIMS score of 14 out of 15 indicating intact cognition. He was independent with most ADLs. Record review of Resident #14's undated care plan reflected he had coronary artery disease r/t HTN and interventions included to give all cardiac medications as ordered by the physician. Resident #14 had chronic pain r/t chronic pain syndrome and interventions included to administer analgesics as ordered by the physician. Record review of Resident #14's active physician orders as of 07/31/2024 reflected an order for CoQ10 (Coenzyme Q10 is an antioxidant that the body produces naturally and that might help treat certain heart conditions, migraines and diabetes) oral capsule 50mg, give 1 capsule by mouth two times a day for congestive heart failure, order date was 07/02/2024. Nifedipine ER 60mg, given by mouth two times a day r/t HTN. Hold for BP less than 110/60, order date was 04/29/2024. Norco 455876 Page 8 of 10 455876 08/01/2024 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0880 (Hydrocodone-Acetaminophen), give 1 tablet by mouth every 8 hours for pain, order date was 04/27/2024. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #14's MAR for July 2024 reflected CoQ10 50mg, Nifedipine ER 60mg and Norco tablet 10-325mg was documented as administered on 07/31/2024 at 4:00 PM by MA S. Resident #14's vitals were documented as BP 115/78 and pulse56. Residents Affected - Some Record review of Resident #10's face sheet dated 07/31/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] and originally admitted on [DATE]. Her diagnoses included acute respiratory failure, pneumonia, heart failure, HTN, breast cancer, adult failure to thrive, malnutrition, GERD and COPD. Record review of Resident #10's quarterly MDS dated [DATE] reflected a BIMS score of 10 out of 15 indicating moderate cognitive impairment. She required supervision to moderate assistance with most ADLs. Record review of Resident #10's undated care plan reflected she was at high risk for communicable respiratory infections, and she was dependent on staff for all her needs. Resident #10 has GERD and at risk for dysfunctional GI motility. Interventions included give medications as ordered. Record review of Resident #10's active physician orders as of 07/31/2024 reflected an order for Sennosides 8.6mg, give 1 tablet by mouth two times a day for constipation, order date was 07/22/2024. Guaifenesin liquid 100mg/5ml, give 10ml by mouth every 4 hours for cough. Order date was 07/02/2024. Med Pass 2.0, three times a day for protein calorie malnutrition until 08/08/2024. Order date was 07/08/2024. Record review of Resident #10's MAR for July 2024 reflected the Sennosides 8.6 mg tablet, the Med Pass 2.0 90ml, and the Guaifenesin Liquid was documented as administered by MA S at 4:00 pm. During observation and interview on 07/31/2024 between 3:31 PM and 3:50 PM revealed MA S administered Carvedilol 6.25mg tablet by mouth to Resident #4. MA S then moved on the Resident #14, checked his BP and pulse, administered Coenzyme Q10, Nifedipine ER 60mg and Hydrocodone-acetaminophen 10-325mg. MA S moved on to Resident #10 and administered Sennosides 8.6mg, Guaifenesin 10ml liquid and 90ml of Med Pass 2.0. MA S did not perform hand hygiene between Residents #4 and #14. MA S did not perform hand hygiene after Resident #10. MA S stated she was nervous and forgot to sanitize her hands between residents. MA S stated hand hygiene is doe to help prevent transfer of germs from one resident to another. In an interview on 08/01/2024 at 12:45 PM, the DON stated she expected MA S to have performed hand hygiene. The DON stated hand hygiene/hand sanitization during medication pass between residents is done to prevent the spread of infection. The DON stated the Infection Preventionist monitors staff for compliance with infection control practices and that 15 staff are checked for competency every month as well as during annual competency skills checks. The DON states she also performs infection control spot checks when the opportunity arises during resident care. The DON stated moving forward she plans to do more infection control competency checks and observations. Interview on 08/01/2024 at 1:15PM, the Infection Preventionist (IP) stated the staff were supposed to wash hands in between resident care and usually staff carry pocket hand sanitizers. IP stated she did staff in-service once a month, about 15 to 20 staff competency check lists. IP stated she would 455876 Page 9 of 10 455876 08/01/2024 The Woodlands Nursing and Rehabilitation Center 4650 S Panther Creek Drive The Woodlands, TX 77381

F 0880 Level of Harm - Minimal harm or potential for actual harm also do random observations of hand hygiene. IP stated she plans to conduct infection control in-service for MA S. Record review of MA S's Oral Medication Administration Competency Evaluation Worksheet checklist dated 1/10/2024 reflected she met the performance criteria including performing hand hygiene. Residents Affected - Some Record review of the facility policy and procedure for Medication Administration, date implemented on 10/24/2022, read in part: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection 4. Wash hands prior to administering medication per facility protocol and product 15. Observe resident consumption of medication. 16.Wash hands using facility protocol and product 455876 Page 10 of 10