Health inspection·November 9, 2022

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that licensed nurses have the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs for 1 of 22 residents (Resident #54) reviewed for competent nursing staff. Residents Affected - Few The facility failed to follow physician orders for high blood pressure medication with parameters for Resident #54. This deficient practice could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for deterioration in their condition. Findings included: Physician orders dated November 2022 indicated Resident #54, admitted [DATE], was [AGE] years old with diagnoses of hypertension (high blood pressure) and chronic kidney disease. Orders included Clonidine HCL 0.1 mg - Give 1 tablet by mouth every 24 hours as needed for SBP above 170 or DBP above 105. (Blood pressure is read using two numbers. Systolic blood pressure measures the pressure in your arteries when the heart beats. The diastolic blood pressure measures the pressure in your arteries when your heart rests between beats) The November 2022 MAR for Resident #54 included Clonidine HCL 0.1 mg - Give 1 tablet by mouth every 24 hours as needed for SBP above 170 or DBP above 105. Record review of a Entry 5 day MDS for Resident #54 dated 10/27/22 indicated he had medically complex conditions including hypertension and renal disease. Record review of a care plan dated 07/09/21 indicated Resident #54 had diagnoses including high blood pressure and renal disease. Interventions included Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. Document and notify physician of the following s/sx: Edema; unplanned weight gain, neck vein distension; difficulty breathing; increased heart rate; elevated blood pressure. Record review of the November 2022 MAR indicated on the following dates and times, Resident #54 's blood pressure readings were recorded with no indication of clonidine being administered per physician orders: Page 1 of 6 675648 675648 11/09/2022 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0658 *11/2/22 at 8:00 p.m., blood pressure was 161/116; Level of Harm - Minimal harm or potential for actual harm *11/3/22 at 8:00 a.m., blood pressure was 188/110; *11/3/22 at 8:00 p.m., blood pressure was 200/123; and Residents Affected - Few *11/5/22 at 8:00 p.m., blood pressure was 173/100. During an interview on 11/09/22 at 10:00, LVN A said Resident #54's blood pressure would fluctuate, and she didn't know if it was possibly due to his renal status. She said he received blood pressure medication in the evenings and said clonidine 0.1 mg should have been administered per physician ordered parameters and documentation of the November MAR gave no indication of administration. During an interview on 11/09/22 at 10:15 a.m., the DON reviewed Resident #54's November 2022 MAR with surveyor. Her expectations were for licensed staff to follow physician orders and parameters with blood pressure medications and added regarding staff did the nurses re-check blood pressures; did they use a manual or automatic device to obtain blood pressure; was the physician notified? She acknowledged Resident #54 was not administered clonidine HCL 0.1 mg as prescribed by physician and should have been due to the risk of not administering medications as ordered. An Administering Medications policy dated April 2019 provided by the facility indicated the following: .4. Medications are administered in accordance with prescriber orders, including any required time frame. And 11. The following information is checked/verified for each resident prior to administering medications: (a). allergies to medications; and (b) vital signs, if necessary. 675648 Page 2 of 6 675648 11/09/2022 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, usual such as body weight or abnormal lab values for 1 of 22 residents (Residents #57) reviewed for nutrition. Residents Affected - Few The facility failed to communicate to the physician/nurse practitioner the recommendations made by the Registered Dietician for review and implementation for Resident #57 on 10/10/22. This failure could place residents who the Registered Dietitian made recommendations at risk of weight loss and decline in health status. Findings included: Record review of the admission record dated 11/09/22 indicated Resident #57 was admitted [DATE] was [AGE] years old with diabetes, kidney failure, dependence on renal dialysis, anxiety disorder and low back pain. Record review of physician orders dated November 2022 indicated Resident #57 did not have orders for Pro-Stat (A sugar-free, ready-to-drink medical food providing 15 grams of protein) 30 ml po BID for increased protein needs and renal multivitamin tablet po QD. Record review of the MAR for October 2022 indicated Resident #57 was not started on or was given Pro-Stat 30 ml po BID for increased protein needs and renal multivitamin tablet po QD. Record review of the MAR for November 2022 indicated Resident #57 was not started on or was given Pro-Stat 30 ml po BID for increased protein needs and renal multivitamin tablet po QD. Record review of the registered dietician progress notes for Resident #57 dated 10/10/22 indicated Most recent labs done on 10/05/2022. Most recent albumin level is 3 . Most recent sodium level is 128 . Nutritional diagnosis is increased energy and protein needs related to hemodialysis and pressure injury. she made recommendations of a nutrition prescription was as follows: 1. add Pro-Stat 30 ml po BID for increased protein needs. 2. add renal multivitamin tablet po QD. 3. continue weekly weights. Record review of nurse's notes for Resident #57 dated 10/10/22 to 11/09/22 indicated no evidence of physician or nurse practitioner being notified of the dietary recommendations. Record review of the MDS dated [DATE] indicated Resident #57's cognition intact and received supervision with feeding herself and received extensive with assistance with all other ADLs. Record review of the care plan dated 10/24/2022 indicated Resident #57 had nutritional problem or potential nutritional problem R/T high BMI (Body Mass Index), Stage 2 PU (Pressure Ulcer), Dialysis and fluid restriction. approaches were as follows: The resident will maintain adequate nutritional 675648 Page 3 of 6 675648 11/09/2022 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0692 status as evidenced by maintaining weight, no s/s of malnutrition, and consuming adequate percentages of meals daily through review date. Approaches included: Level of Harm - Minimal harm or potential for actual harm o Obtain and monitor labs as ordered, report results to physician and follow up as Residents Affected - Few o RD (Registered Dietician) to evaluate resident as needed. o Staff to monitor weight and report significant findings to physician as needed. o Staff to serve diet as ordered and monitor/record intake with meals. o Wound Care Specialist to evaluate and treat as needed. During an interview on 11/09/22 at 8:08 a.m., the DON said she placed a red check mark to indicate she followed up on the recommendation for Resident #57 on her list of dietary recommendations received from the dietician. She said there were no orders to start or to delete the recommendation as she reviewed physician's orders in the electronic record for Resident #57. She said the recommendation was not placed on the October MAR to start the pro-stat or renal vitamin. The DON said she had 30 days per the facility policy to follow up with the physician and would provide the policy. During an interview on 11/09/22 at 9:33 a.m., Registered Dietician B said she had made a recommendation on 10/10/22 for Resident #57 and should have been sent to the doctor. She said the DON asked her to review Resident #57 today. She reviewed the resident and asked for repeat lab or obtain lab results from dialysis to see if orders were still needed because things can change in 30 days in Resident #57's condition could have changed. During an interview on 11/09/22 at 10:34 a.m., the DON said she had been trained to send the dietary recommendations to the physician or to the nurse practitioner for directions and or orders. She said the negative outcome would be on an individual case by case basis. The DON said she could not really say what the negative outcome would be and had not seen any negative outcome with Resident #57. The DON said the facility did not have a policy or procedure about following up with the physician after the dietician gives recommendations. During an interview on 11/09/22 at 11:12 a.m., Nurse practitioner C said she or the primary physician had never been informed about the dietary recommendations for Resident #57 and said she was unaware of any negative outcomes. The policy titled Dietician dated October 2017 indicated A qualified, competent, and skilled dietician will help oversee the food and nutrition services in the facility.9. Our facility's Dietician is responsible for, but not necessarily limited to: a. Assessing nutritional needs of residents; . 675648 Page 4 of 6 675648 11/09/2022 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

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 interview and record review, the facility failed1`to ensure that it's residents are free of any significant medication errors for one of 22 observed for significant medication errors. (Resident #54) Residents Affected - Few The facility failed to follow physician orders for high blood pressure medication with parameters for Resident #54. This deficient practice could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for deterioration in their condition. Findings included: Physician orders dated November 2022 indicated Resident #54, admitted [DATE], was [AGE] years old with diagnoses of hypertension (high blood pressure) and chronic kidney disease. Orders included Clonidine HCL 0.1 mg - Give 1 tablet by mouth every 24 hours as needed for SBP above 170 or DBP above 105. (Blood pressure is read using two numbers. Systolic blood pressure measures the pressure in your arteries when the heart beats. The diastolic blood pressure measures the pressure in your arteries when your heart rests between beats) The November 2022 MAR for Resident #54 included Clonidine HCL 0.1 mg - Give 1 tablet by mouth every 24 hours as needed for SBP above 170 or DBP above 105. Record review of a Entry 5 day MDS for Resident #54 dated 10/27/22 indicated he had medically complex conditions including hypertension and renal disease. Record review of a care plan dated 07/09/21 indicated Resident #54 had diagnoses including high blood pressure and renal disease. Interventions included Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. Document and notify physician of the following s/sx: Edema; unplanned weight gain, neck vein distension; difficulty breathing; increased heart rate; elevated blood pressure. Record review of the November 2022 MAR indicated on the following dates and times, Resident #54 's blood pressure readings were recorded with no indication of clonidine being administered per physician orders: *11/2/22 at 8:00 p.m., blood pressure was 161/116; *11/3/22 at 8:00 a.m., blood pressure was 188/110; *11/3/22 at 8:00 p.m., blood pressure was 200/123; and *11/5/22 at 8:00 p.m., blood pressure was 173/100. During an interview on 11/09/22 at 10:00, LVN A said Resident #54's blood pressure would fluctuate, 675648 Page 5 of 6 675648 11/09/2022 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and she didn't know if it was possibly due to his renal status. She said he received blood pressure medication in the evenings and said clonidine 0.1 mg should have been administered per physician ordered parameters and documentation of the November MAR gave no indication of administration. During an interview on 11/09/22 at 10:15 a.m., the DON reviewed Resident #54's November 2022 MAR with surveyor. Her expectations were for licensed staff to follow physician orders and parameters with blood pressure medications and added regarding staff did the nurses re-check blood pressures; did they use a manual or automatic device to obtain blood pressure; was the physician notified? She acknowledged Resident #54 was not administered clonidine HCL 0.1 mg as prescribed by physician and should have been due to the risk of not administering medications as ordered. An Administering Medications policy dated April 2019 provided by the facility indicated the following: .4. Medications are administered in accordance with prescriber orders, including any required time frame. And 11. The following information is checked/verified for each resident prior to administering medications: (a). allergies to medications; and (b) vital signs, if necessary. 675648 Page 6 of 6