Inspection·June 10, 2022

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident # 15's Care Plan dated 4/25/2022 revealed the resident had hypotension with the following associated Interventions/Tasks: Give medications as ordered; scheduled Midodrine HCL [hydrochloric acid] 2.5 milligrams at 0900, 1500, 2100 [9:00 AM, 3:00 PM, and 9:00 PM]. Record review of the MRR dated 04/15/2022 for Resident # 15 revealed pharmacist recommendations to add hold parameters on midodrine. Ex. Hold if blood pressure is >120/90. Record review of electronic order revealed Resident # 15 had orders dated 06/07/2022 at 1552 [ 3:52 PM] by PCP A for Midodrine HCL tablet 2.5 milligrams by mouth three times a day for hypotension hold if systolic > 120 or diastolic > 90. Record review of the MAR for June 2022 revealed Resident # 15 received midodrine HCL 2.5 milligrams by mouth three times a day for hypotension with administration instructions hold if systolic > [greater than] 120 or diastolic > 90. The Blood pressure reading for the 9:00 PM dose on 06/07/2022 was documented as 142/83 [systolic /diastolic]. Record review of Resident #15's Blood Pressure Summary tab of the electronic health record revealed on the following blood pressures: -06/07/2022 at 9:53 AM readings of 137/91 and -06/07/2022 at 9:50 PM readings of 142/83. 2. Record review of the admission Record revealed Resident # 25 was a [AGE] year-old man with an initial admission date of 05/03/2022. His diagnoses included: essential (primary) hypertension [type of high blood pressure that doesn't have a known cause]; repeated falls; syncope [fainting, usually caused by sudden drop in blood pressure] and collapse. Record review of the quarterly MDS dated [DATE] revealed Resident # 25 had a BIMS score of 8 indicative of moderately impaired cognition]. Record review of a Care Plan dated 05/24/2022 revealed Resident # 25 had a focus area of hypertension with the following associated Interventions/Tasks: Give antihypertensive medications as ordered. Record review of the MRR dated 04/15/2022 for Resident # 25 revealed pharmacist recommendations to add blood pressure parameters on propranolol. Ex. Hold if blood pressure is <100/60 and HR <60. Record review Resident # 25's of electronic order entry screen revealed orders dated 05/28/2022 at 0630 [6:30 AM] for Propranolol HCL tablet 10 milligrams by mouth one time a day for hypertension hold if BP [blood pressure] is < [less than] 100/60 and HR [heart rate] is <60. Record review of the MAR for May 2022 revealed Resident # 25 received Propranolol HCL 10 milligrams by mouth one time a day for hypertension with administration instructions hold if BP is <100/60 and HR [heart rate] is <60. The Blood pressure reading was 84/51 and the pulse [heart rate] was 96 for the dose administered on 05/30/2022. 3. Record review of the admission Record revealed Resident # 35 was a [AGE] year-old female with an initial admission date of 04/01/2022. Her diagnoses included: secondary hypertension [high blood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House Nursing and Rehabilitation 407 N College St Rosebud, TX 76570 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 pressure difficult to control with a one or two medications]. Level of Harm - Minimal harm or potential for actual harm Record review of the MDS dated [DATE] revealed Resident # 35 had a BIMS score of 7 indicative of severely impaired cognition]. Residents Affected - Some Record review of the Care Plan dated 05/24/2022 revealed Resident # 35 had a focus area of hypertension with the following associated Interventions/Tasks: weigh per facility policy. Additional focus areas included: diuretic therapy related to hypertension with associated interventions that include monitor vital signs, postural hypotension [type of low blood pressure that occurs when standing from seated or supine position]. Record review of the MRR dated 04/15/2022 for Resident # 35 revealed pharmacist recommendations to add blood pressure parameters on hydrochlorothiazide [a medication affecting blood pressure]. Ex. Hold if blood pressure is <100/60. Record review of Resident #35's electronic order entry screen revealed orders dated 05/01/2022 at 0630 [6:30 AM] for Hydrochlorothiazide tablet 12.5 milligrams by mouth one time a day, hold if BP <100/60. Record review of the MAR for May 2022 and June 2022 revealed Resident # 35 received Hydrochlorothiazide tablet 12.5 milligrams by mouth one time a day, with administration instructions to hold if BP <100/60 without documentation of blood pressure on the MAR. Record review of the Blood Pressure Summary tab of the electronic health record revealed documentation for Resident # 35 were on the following dates: 04/01/2022, 04/04/2022, 04/05/2022, 04/07/2022, 04/08/2022, 04/09/2022, 04/12/2022, 04/15/2022, 04/22/2022, 04/29/2022, 05/09/2022, 05/20/2022, and 06/03/2022. In an interview on 06/09/2022 at 11:30 AM with the DON, she stated she had a message back from prescribing physician who recommend Midodrine for Resident # 15 indicating blood pressure monitoring not necessary at the 2.5 milligram dosing. The DON stated that medications that require blood pressure or heart rate monitoring prior to administration require the blood pressure or heart rate be entered into the electronic MAR prior to administering the medication. The DON stated the MAR will reflect the blood pressure or heart rate measurements when printed. The DON stated the training and expectation is for blood pressure or heart rate measurements to be obtained prior to administering such medications for patient safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage House Nursing and Rehabilitation 407 N College St Rosebud, TX 76570 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 17 rooms (#105) observed, in that: The wood windowsill in room [ROOM NUMBER] was cracked and the wood was splintered with 4 nails sticking out under the sill. This deficiency could affect residents by causing splinters and skin tears by the wood or the nails. The findings were: Observation on 6/7/2022 at 2:43 p.m. of room [ROOM NUMBER] revealed the wood windowsill was cracked and splintered. Further observation below the windowsill revealed there were 4 nails sticking out along the length of the windowsill. Interview on 6/8/2022 at 2:23 p.m., the Maintenance Supervisor, after he observed the windowsill revealed he was not aware the sill was cracked. He stated it most likely occurred when staff raised bed B's electric bed and it was too close to the window, causing it to crack. The Maintenance Supervisor also found a board that had come off from the bottom of the windowsill. Interview on 6/8/2022 at 2:34 p.m. with the Maintenance Supervisor reported staff notified him of any repairs that need to be done either by just telling him in person or by placing a maintenance request in the Kios communication system. The Maintenance Supervisor reported anything could happen in reference to how the cracked windowsill could affect the residents but he did not elaborate. The facility did not have a policy related to damage in resident rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675210 If continuation sheet Page 4 of 4