Health inspection·January 27, 2023

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. Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one (Hall 200 nurse medication cart) of four nurse medication carts for drug storage, as evidenced by: -Nurse medication cart on Hall 200 had medication on top of cart and was unattended This deficient practice could place 27 residents who reside on Hall 200 at risk for harm and place the facility at risk for possible drug diversion. The findings include: Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of four nurse medication carts (Hall 200 nurse medication cart) reviewed for drug storage, as evidenced by: -Nurse medication cart on Hall 200 had medication on top of cart and was unattended This deficient practice could place residents who reside on Hall 200 at risk for harm and place the facility at risk for a possible drug diversion. The findings include: Observed on 1/27/2023 at 9:07 am on top of medication cart in 200 Hall a bag of liquid medicine labeled Piperacillin Sodium-Tazobactam Sodium (PIP/Tazo) 3.375/NS in 100 ml Normal Saline (NS)(solution to supply water and salt (sodium chloride) to the body) unattended until 9:11 am (PIP/Tazo is a medication given for infection (An infection is the invasion of tissues by pathogens (is any organism or agent that can produce disease), their growth, and the reaction of host tissues to the infectious agent and the toxins they produce)). LVN A approached the medication cart. Interviewed LVN A on 1/27/2023 at 9:11 am she stated she is not supposed to leave medication on top of the cart unattended, as it can be dangerous to other residents and compromise patient privacy. She stated she went to retrieve intravenous (IV), (medicine that goes into the veins) flushes (syringes filled with normal saline (solution to supply water and salt (sodium chloride) to the body) for the intravenous (IV) medication to be administered into the residents' vein. Interviewed the IP on 1/27/2023 at 11:17 am he said medications should be locked in medication (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675894 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 675894 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor of Conroe 1600 Grand Lake Dr Conroe, TX 77301 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)