Health inspection·February 1, 2024

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was assessed and had consents for bed rails for 2 of 3 residents (Resident #46 and Resident #6) reviewed for bed rails. -The facility failed to obtain consent prior to installing and utilizing bedrails for Residents #46 and #6. These failures could affect residents who utilized some type of bed rails in the facility and could put the residents at risk for potential injuries. Findings included: Record review of Resident #46's face sheet dated 01/31/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinsonism (a group of conditions that affect movement and mimic Parkinson's disease), dementia, chronic pain, anxiety, constipation, HTN (elevated blood pressure) and depression. Record review of Resident #46's annual MDS dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. He was dependent on staff for dressing and personal hygiene. He required partial/moderate assistance with turning in bed and was dependent on staff when moving from sitting to lying and lying to sitting. He was receiving hospice care. Further review revealed no bed rails were used. Record review of Resident #46's undated care plan revealed: Focus - Resident #46 utilized an enabling device to help with positioning and/or promote independence. Date initiated was 12/22/2022. Goal Resident #46 will utilize enablers to promote increased independence. Interventions included: educate resident/or resident representative on risks and benefits of assistive device, including risk of entrapment if applicable. Ensure valid consent uploaded to resident's record prior to initiating side rails. Side rails: quarter size enabler device side per physician order for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Record review of Resident #46's active physician's orders as of 01/31/2024 revealed no orders for side rail use as indicated in the care plan. Record review of Resident #46's unsigned bed rail evaluation dated 12/19/2023 revealed the recommendations were removal of the bed rails as they did not meet the resident's needs. Page 1 of 8 675648 675648 02/01/2024 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0700 Record review of Resident #46's electronic medical records revealed no signed consent for bed rails. Level of Harm - Minimal harm or potential for actual harm Observation on 01/30/2024 at 9:55 AM, revealed Resident #46 was lying on his back in bed. The bed was up against the wall to the left of the resident and the bed side rail was raised on the left of the resident. The bed rail was approximately 2 feet in length. The bed side rail to the right of the resident was in the lowest position . Residents Affected - Few Record review of Resident #6's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included stroke, respiratory failure, traumatic brain injury, encephalopathy (disorder of the brain that affects its function or structure), muscle wasting, joint pain, paranoid schizophrenia, contracture of muscle to the left upper arm and to the left lower leg. Record review of Resident #6's quarterly MDS dated [DATE] revealed he had no speech; he sometimes expressed ideas and wants. He sometimes understood others. He had impaired vision. He had short term and long-term memory problems. His cognitive skills were severely impaired. He was dependent on staff for all ADLs. Further review revealed no bed rails were used. Record review of Resident #6's care plan revealed: Focus - Resident #6 was a moderate risk for falls. Goal - Resident #6's risk and injury potential will be minimized through the next review date. Interventions included: adaptive devices as recommended by therapy or MD. Observe for safe use. Observe to ensure appropriate use of safety/assistive devices. Record review of Resident #6's active physician's orders as of 01/31/2024 revealed no orders for assistive devices. Record review of Resident #6's Bed Rail Safety Review dated 10/20/2023 and e-signed by the ADON on 12/05/2023 revealed the recommendations were to remove bed rails as they do not meet the resident's needs. Record review of Resident #6's electronic medical records revealed no signed consent for bed rails. Observation on 01/30/2024 at 10:10 AM, revealed Resident #6 was in bed, awake and did not respond to greeting. He had severe contractures to his left arm and hand. A grab bar attached to the bed frame on the resident's left side was raised in a locked position. The bed was up against the wall to the right of the resident and there was no bed rail to the right of the resident. Interview on 02/01/2023 at 10:00 AM, Resident #46 said he used the siderail to hold himself up when brief was changed. In a telephone interview on 02/01/2024 at 10:20 AM, the RP for Resident #6 stated she filled out paperwork in June or July 2023 but could not recall if she signed a consent for bedrails. The RP stated it was news to her about the bedrail and that there were no bed rails when she last visited about one week ago. Interview on 02/01/24 at 8:45 AM, the Surveyor requested bed rail consents for Resident #46 and #6. The Administrator said there were no consents. The Administrator said the ADON was responsible for bed rail evaluations. 675648 Page 2 of 8 675648 02/01/2024 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/01/2024 at 10:13 AM, Surveyor attempted to contact Resident #46's RP via telephone to inquire about consent for bed rails. There was no answer and unable to leave a message d/t the voicemailbox was full. Interview on 02/01/2024 at 11:10 AM, the ADON stated risks to a resident using bed side rails would be injury. She stated Resident #46 and Resident #6 were both low risk for injury. The ADON stated for Resident #46, he was very dependent on staff at this point in his illness. She stated he probably wanted to be able to use the side rail for turning and thought he still could. She stated Resident #46's bed rail to the right of the resident was zip tied in the downward position . She stated the bed rail could not be moved, therefore did not think that would be an issue. She stated the bed rail on the other side was not tied down. She stated the bed for Resident #46 came from hospice services and it came with the bedrails. The ADON stated she was unaware Resident #6 had a bed rail. The ADON stated Resident #6 could not move at all so bed rails would be of no benefit. She said bed rails for Residents #46 and #6 would be removed immediately. She stated if Resident #46 should request bed rails, then he would be reevaluated . Record review of the facility policy for Bed Safety and Bed Rails, revised August 2022, read in part: .Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Policy Interpretation and Implementation .8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent 675648 Page 3 of 8 675648 02/01/2024 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 1 of 10 residents (Resident #34) and 1 of 3 medication Carts (200 Hall Back Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure the 200 Hall Back Nursing Cart did not contain expired Basaglar Insulin for Resident #34. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings Included: Record review of Resident #34's Face Sheet dated 01/31/24 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of: right dominance paralysis, muscle weakness and type 2 diabetes. Record review of Resident #34's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, use of a wheelchair and dependent for most ADLs. Record review of Resident #34's undated Care Plan revealed, focus- patient has diabetes and takes Basaglar insulin as directed; intervention- diabetes medication as ordered by doctor. Record review of Resident #34's Order Summary Report dated 01/31/24 revealed, Basaglar Insulin- inject 25 units under the skin two times a day for type 2 diabetes effective 05/09/23. Record review of Resident #34's January MAR dated 01/31/24 revealed, - 01/31/23 at 05:00 Basaglar- 25 units under the skin for type 2 diabetes. In an observation and Interview on 01/31/24 at 08:55 AM, inventory of the 200 Hall Back Nursing Cart with LVN J revealed: - An open in-use and expired Basaglar Insulin Pen for Resident #34 with a DO NOT USE AFTER 01/29/24 label. LVN J said nursing staff were expected to check their carts daily as used for expired medications. She said all multidose insulin containers were additionally labeled with the open or use by date. LVN J said when insulin expired it may become less effective and its use could place residents at risk for uncontrolled blood sugars. LVN J said since the insulin pen label said it expired on 01/29/24 it should be discarded in the sharps container and reordered from the pharmacy. In an interview on 01/31/24 at 11:33 AM, the DON said nursing staff were expected to check their carts daily at the beginning of their shift for expired, inappropriately stored and inappropriately labeled medications. She said ultimately the ADON, DON were responsible for ensuring the carts were 675648 Page 4 of 8 675648 02/01/2024 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monitored and perform audits of carts every other week to ensure nursing staff were maintaining their carts The DON said after insulin expired it became less potent and use could result in uncontrolled blood sugars so it must be reordered from the pharmacy and discarded in the sharps containers located on the medication carts. Record review of the facility policy titled Storage of Medications revised 11/2020 revealed, 4- discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of the facility policy titled Medication Storage in the facility revised 08/2014 revealed, G- all expired medications will be removed from the active supply and destroyed in the facility regardless of the amount remaining. The medication will be destroyed in the usual manner. 675648 Page 5 of 8 675648 02/01/2024 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 upon observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and under proper temperature controls for 3 out of 10 residents (Resident #2, Resident #13 and Resident #25) and 2 of 3 medication carts (100 Hall Nursing Cart and 200 Hall Front Nursing Cart) reviewed for drug labeling and storage. - The facility failed to ensure the 100 Hall Nursing Cart Nursing Cart did not contain an in-use insulin pen for Resident #25 with no open date. - The facility failed to ensure the 200 Hall Front Nursing Cart did not contain open and in-use Acidophilus probiotic with manufacturers' instructions to refrigerate after opening and in-use insulin pens for Resident #13 and Resident #25 with no open date This failure could place residents at risk of adverse medication reactions and drug diversions. Findings included: 100 Hall Back Nursing Cart Record review of Resident #25's Face Sheet dated [DATE] revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of: anxiety disorder, high cholesterol, stomach ulcer and type 2 diabetes. Record review of Resident #25's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, use of a wheelchair and supervision for most ADLs. Record review of Resident #25's undated Care Plan revealed, focus- resident has orders for insulin r/t type 2 diabetes; intervention- administer insulin as ordered. Record review of Resident #25's Order Summary Report dated [DATE] revealed, Insulin Lispro- inject 5 units under the skin three times a day for diabetes. In an observation and interview on [DATE] at 08:20 AM, inventory of the 100 Hall Nursing Cart with LVN H revealed: - An open an in-use Insulin Lispro Pen for Resident #25 with no open date. LVN H said nursing staff are expected to check their carts daily for inappropriately labeled medications. She said insulin must be labeled with the date opened in order to track the expiration date because when insulin expired it becomes less effective. LVN H said since the insulin pen did not have an open date it must be discarded in the sharps container because use of expired insulin could place residents at risk for uncontrolled blood sugars. 200 Hall Front Nursing Cart 675648 Page 6 of 8 675648 02/01/2024 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0761 Resident #2 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility with diagnoses of: reduced mobility, lack of coordination, depression and type 2 diabetes. Residents Affected - Some Record review of Resident #2's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, substantial assistance with most ADLs, and always incontinent of both bladder and bowel. Record review of Resident #2's undated Care Plan revealed, focus- diagnosis of diabetes; interventionadminister medications as ordered. Record review of Resident #2's Order Summary Report dated [DATE] revealed, - Insulin Lispro- inject insulin as per sliding scale : if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 - 999 = 12, for type 2 diabetes Resident #13 Record review of Resident #13's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] revealed, paralysis, difficulty swallowing, muscle weakness and wasting and type 2 diabetes. Record review of Resident #13's MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, dependent for most ADLs, always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #13's undated Care Plan revealed, focus- order for insulin r/t diabetes; intervention- administer insulin as ordered. Record review of Resident #13's Order Summary Report dated [DATE] revealed, - NovoLIN N Insulin- inject 12 units under the skin at bedtime for type 2 diabetes - NovoLIN N Insulin- inject 21 units under the skin one time a day for type 2 diabetes. In an observation and interview on [DATE] at 08:35 AM, inventory of the 200 Front Nursing Cart with LVN P revealed: - An open and in-use Insulin Lispro Pen for Resident #2 with no open date. - An open and in-use Novolin N insulin pen for Resident #13 with no open date - 1 open and in-use bottles of Acidophilus probiotic with open date of [DATE] and manufacturer's instructions of store unopened container at room temperature, REFRIGERATE AFTER OPENING. - 1 open and in-use bottles of Acidophilus probiotic with open date of [DATE] and manufacturer's instructions of store unopened container at room temperature, REFRIGERATE AFTER OPENING. 675648 Page 7 of 8 675648 02/01/2024 Conroe Health Care Center 2019 N Frazier Conroe, TX 77301

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN P said nursing staff are expected to check their carts daily for inappropriately labeled medications as well as medications stored at the wrong temperature. She said medications that required refrigeration must be refrigerated because it might be not work if left at room temperature. LVN P said the bottles of Acidophilus were always left in the carts, she did not know that the facility's selected Acidophilus required refrigeration after opening and since it was at the wrong temperature it must be discarded. She said multi-dose insulin containers should be labeled with the date opened in order to track the expiration date. LVN P said since the insulin pens had no open dates they might be expired and since expired insulin is less effective it must be discarded in the sharps container. She said the use of expired insulin could place residents at risk for uncontrolled blood sugars. In an interview on [DATE] at 11:33 AM, the DON said nursing staff are expected to check their carts daily at the beginning of their shift for expired, inappropriately stored and inappropriately labeled medications. She said ultimately the ADON, DON were responsible for ensuring the carts are monitored and perform audits of carts every other week to ensure nursing staff maintained their carts. She said once a multi-dose container such as insulin is opened it must be labeled with a date order in order to track the expiration date and insulin pens with no open dates cannot be used since their expiration date cannot be determined and they might be expired. The DON said after insulin expired it became less potent and use can result in uncontrolled blood sugars so it must be reordered from the pharmacy and discarded in the sharps containers located on the medication carts. The DON said medications should be stored at the manufacturers specified temperatures and when medications are stored at the wrong temperature there could be an unknown impact on their efficacy. She said the used of expired or inappropriately labeled medications could place residents at risk for adverse reactions and have unpredictable effects on health conditions. Record review of the facility policy titled Storage of Medications revised 11/2020 revealed, 4- Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. 7- Medications requiring refrigeration are stored in a refrigerator in the drug room at the nurses' station or other secured location. 675648 Page 8 of 8