Health inspection·May 29, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 6 residents (Resident #43) reviewed for ADLs. Residents Affected - Few The facility failed to ensure Resident #43 was provided personal grooming (long fingernails and dark substance under the fingernails) and oral hygiene (dirty teeth and bad breath) by facility staff. These failures could place residents at risk for not receiving the assistance needed for daily care and services to help prevent infection or injuries. Findings included: Record review of Resident #43 face sheet dated 05/29/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), history of klebsiella pneumoniae (a bacterial infection), history of viral pneumonia (lung infection), dysphagia (swallowing disorder) and aphasia (a language disorder) following a stroke; hemiplegia and hemiparesis (paralysis to one side of body affecting the right dominant side) following a stroke; tracheostomy status (a condition of a person who had undergone medical procedure to create an opening in the windpipe to facilitate breathing), gastrostomy status (a condition of a person who had undergone a procedure to make a hole into the stomach through the abdomen to insert a feeding tube) and colostomy status (a condition of a person who had undergone a procedure to make an opening in the large intestine to divert stool). Record review of Resident #43's quarterly MDS (a tool for resident assessment and care screening) dated 05/07/25 indicated a BIMS score of 12 out of 15 indicating moderately impaired cognition. Resident #43 had impairment to both upper and lower extremities. Resident #43 required substantial assistance with oral hygiene: the helper did more than half of the effort. Resident #43 was dependent on staff for personal hygiene and required substantial assistance with mobility. Record review of Resident #43's undated care plan included: Focus - Resident #43 had a tracheostomy and a high risk for infection and aspiration. Interventions included provide good oral care daily and as needed. Focus - Resident #43 requires tube feeding and nothing by mouth, r/t dysphagia. Interventions did not include to provide oral care. Focus - Resident #43 had left sided weakness r/t stroke. Interventions included, to assist with ADLs and mobility as needed. Focus - Resident #43 exhibited ADL self-care performance deficit and required assistant due to limited mobility. Interventions included, provide maximum assistance of 1 to 2 staff for all ADLs; provide assistance with eating, Page 1 of 4 675894 675894 05/29/2025 Park Manor of Conroe 1600 Grand Lake Dr Conroe, TX 77301

F 0677 dressing, bathing, toileting and grooming as needed. Level of Harm - Minimal harm or potential for actual harm In an observation on 5/28/25 at 7:25 AM, Resident #43 was lying in bed with the head of bed elevated. A flexible respiratory tubing was connected to his tracheostomy. The tubing was connected to a compressor delivering humidified air. He had long jagged fingernails on his left hand with brownish-black matter under each fingernail. Residents Affected - Few In an observation and interview on 5/29/25 at 6:57 AM, Resident #43 was awake, alert and tracking surveyor with his eyes. The RT uncovered the resident's right hand. Resident #43 was able to open his fist when instructed. The fingernails on the right hand were approximately 0.5 cm long, square shaped with sharp corners. The fingernails on the left hand were approximately 0.5cm long, jagged, sharp corners and had dark matter under each fingernail. Resident #43 had dry lips; his teeth were filmy with white substance between the teeth. He was able to cough and clear white frothy sputum from his tracheostomy. His breath had an odor. The resident was asked if he had fingernails cleaned and trimmed recently or had oral care recently. Resident #43 stared at the Surveyor, did not respond nor nod or shake his head. The RT stated he would sometimes not respond to strangers. The RT stated that she did not provide oral care and that the nursing staff were responsible to provide oral care. In interview and observation on 5/29/25 at 7:08 AM, CNA-A stated she had not worked with Resident #43 very often and that she had not seen him yet as she was tending to other residents at the time. CNA-A walked into Resident #43's room to check on him. CNA-A stated that his fingernails on the right hand, could use some cleaning and that keeping them long would risk cutting himself and causing infection. CNA-A stated that the fingernails on his right hand needed to be trimmed as well. CNA-A stated for his dry lips she would use a wet washcloth and wet his mouth. CNA-A stated she was not sure if the black matter under his fingernails was his baseline. In an interview on 5/29/25 at 7:16 AM, LVN-B stated Resident #43 needed nailcare and that the fingernails on the left hand should be clean and trimmed as they could cause infection. LVN-B stated the nursing staff was responsible to provide nailcare as needed. LVN-B stated the nurses were responsible for oral care. LVN-B stated having dry lips could irritate Resident #43 and if his mouth is not clean then germs can grow in his mouth. LVN-B stated as a nurse it was his responsibility to ensure nailcare and mouth care was completed. LVN-B stated he would take care of this right away. In an interview on 5/29/25 at 7:27 AM, CNA-C stated nailcare was done as needed and every Sunday for all residents. CNA-C stated she completed head to toe check on all her residents every 2 hours. CNA-C was not assigned to Resident #43. CNA-C stated residents can get sick from having long and dirty fingernails because food and germs can get under the nails as residents will often put their hands into their mouths. CNA-C stated long, and dirty fingernails could dig into the skin causing cuts and infection. CNA-C stated mouth care is provided every morning and that the risks to the resident would be red gums, odors, bacteria, and problems with eating. In an interview on 5/29/25 at 7:36 AM, LVN-D stated nailcare can be done by the CNAs unless the resident was diabetic, then the nurses will do the nailcare. LVN-D stated if she saw long and dirty nails the risks would be infection. LVN-D stated oral care would be provided by nurses and CNAs. LVN-D stated signs and symptoms of infection could be a white tongue and odors. LVN-D stated if a resident had filmy teeth they may not want to eat, they may have mouth pain, it could lead to weight loss and dry, cracked lips could be a sign of dehydration. In an interview on 5/29/25 at 7:46 AM, the DON stated the nursing staff did nailcare every Sunday 675894 Page 2 of 4 675894 05/29/2025 Park Manor of Conroe 1600 Grand Lake Dr Conroe, TX 77301

F 0677 Level of Harm - Minimal harm or potential for actual harm and as needed. The DON stated mouth care should be done daily, every shift and as needed. The DON stated the respiratory therapist, nurses and CNAs could do mouth care. The DON stated having long and dirty fingernails could affect Resident #43's personal hygiene. The DON stated Resident #43 does use his left hand often and would handle newspaper with ink. The DON stated moving forward she would conduct staff inservices regarding oral care and nail care. Residents Affected - Few In an interview on 5/29/25 at 8:28 AM, LVN-E stated he audited resident nails weekly and documented on the Nail Care Log sheet. He confirmed that on 5/26/25 he checked Resident #43's nails and documented on the Nail Care Log sheet. LVN-E stated Resident #43's fingernails did look a little sharp. LVN-E stated Resident #43 refused nail trim on 5/26/25 and that he cleaned under the fingernails. LVN-E stated Resident #43 would scratch and get dead skin under the nails. LVN-E stated Resident #43 developed dirty nails fast and he had seen Resident #43 grab the newspaper at times. LVN-E stated he expected nailcare to be provided every Sunday and as needed per facility policy and procedure. LVN-E stated he expected clean nail beds and trimmed as comfortable as possible. LVN-E stated he could not say exactly why Resident #43 had dark matter under the fingernails. In an interview on 5/29/25 at 2:40 PM, the DON stated CNA-F worked with Resident #43 on 5/28/25, when asked who provided nail care on 5/28/25 at 12:51 PM. In an interview on 5/29/25 at 2:45 PM, LVN-B stated he would communicate completion of nailcare and mouth care for Resident #43 by passing the information to the oncoming nurse during shift report. LVN-B stated he would not document the completed task in the chart because he considered it standard nursing care. In an interview on 5/29/25 at 2:50 PM, LVN-D stated if nailcare or mouth care was done, she would document a progress note in the resident's chart and include details because it would be an assessment. LVN-D stated if not documented then it was not done and that it was the facility policy and procedure to do so. In a telephone interview on 5/29/25 at 3:05 PM, CNA-F confirmed she worked with Resident #43 on 5/28/25 and that she provided nailcare by washing his arms, hands and removing dirt from his fingers. CNA-F stated Resident #43 would always get black ink on his fingers because he handles black ink on newspaper. Record review of Resident #43's Plan of Care Response History for Nail Care dated 5/29/25, indicated on 5/28/25 at 12:51 PM, Resident #43 received nail care. Further review did not indicate who the staff member was that provided the care. Record review of the facility's Nail Care Log dated 5/5/25, 5/12/25, 5/19/25, 5/26/25, 400 Hall, indicated Resident #43 had his nails cut on each of those days. Further review indicated the following instruction: Progress note stating completed; if resident refused MD/RP notified and progress note stating this was completed. The log sheet did not include who provided the nail care. Record review of Resident #43's progress notes dated 5/29/25 with the effective date range of 04/29/25 to 5/30/25 revealed no progress note regarding Resident #43's refusal of nail trimming on 5/26/25 as reported by LVN-E. Record review the facility policy and procedure for Care of Fingernails/Toenails, revised April 2007, read in part: .the purpose of this procedure are to clean the nail bed, to keep mails trimmed, 675894 Page 3 of 4 675894 05/29/2025 Park Manor of Conroe 1600 Grand Lake Dr Conroe, TX 77301

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and to prevent infection .General Guidelines 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed .4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .10. Gently remove the dirt from around and under each nail with an orange stick .13. Trim fingernails in an oval shape .14. Smooth the nails with a nail file or emery board .The following information should be recorded in the resident's medical record .1 .date and time .2. the name and title of the individual who administered the nail care. 3. The condition of the resident's nails and nail bed .6. If the resident refused the treatment, the reason(s) why and the interventions taken . Record review of the facility policy and procedure for Mouth Care, revised April 2007, read in part: The purpose of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth .the following information should be recorded in the resident's medical record: 1. The date and time the mouth care was provided .who provided mouth care. All assessment data obtained concerning the resident's mouth .Reporting 1. Notify the supervisor if the resident refuses the mouth care . Record review of the facility's undated admission Packet read in part: Acknowledgement and Consent of Treatment .I hereby acknowledge and consent for the facility .to provide the necessary care and treatment while the patient resides in the facility . 675894 Page 4 of 4