Health inspection·August 24, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement an accurate comprehensive person- centered care plan for 1 of 5 residents (Resident #1) The facility failed to ensure Resident #1's comprehensive care plan included the resident's use of oxygen and pacemaker. This failure could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Findings included: Electronic record review of Resident #1's face sheet revealed an [AGE] year-old who was initially admitted to the facility on [DATE] and re-admitted [DATE] with a diagnoses of End stage renal disease, essential (Primary) Hypertension, Gastrointestinal hemorrhage, anxiety disorder, major depressive disorder, presence of cardia pacemaker, (Congestive) heart failure. Record review of Resident #1's Last quarterly MDS dated [DATE] revealed resident was not assessed for a BIMS score. Section O did not reveal: Oxygen in use while in the facility . Record review of Resident #1's annual Comprehensive Care Plan dated 8/11/23 revealed she was not care planned to be on oxygen or for her pacemaker. Record review of Resident #1's physician's order dated 8/11/23 revealed O2 at 2 L/Minute via NC continuously, O2 at 2 L/Minute via NC PRN, O2 at 2 L/Minute via NC PRN and O2 sats Q Shift and PRN. A review of Resident #1's MDS assessment dated [DATE] did not list Resident #1 to have a pacemaker. Observation and interview on 8/22/23 at 11:15a.m., revealed Resident #1 was in bed alert and oriented. Her left upper arm had bandages resulting from dialysis appointment. Observation revealed Resident #1 had a nasal cannula in one nostril and her oxygen machine was set at 03 level. Resident #1 was told the nasal cannula was on incorrectly as it was only in one nostril (right) and the other part was on the side of the right nostril. Resident #1 removed the cannula, looked at it, smiled and put it back on correctly. Resident #1 stated the oxygen made her feel better. Page 1 of 4 676059 676059 08/24/2023 Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 8/24/23 at 3:30 p.m., with the DON regarding care planning. She stated all (herself, ADON, MDS, SW, Dietary and the resident) are responsible for care planning. She stated, regarding the O2 orders, staff should have identified that error. Interview on 8/24/23 at 3:50 p.m., with the ADON regarding care planning. She stated while all staff are responsible for care planning, she and the Unit Manager, and PPS are responsible for ensuring accuracy when a resident is readmitted . The ADON stated the resident's O2 orders came in a batch order, and it was the responsibility of the nurse to review the orders and document. She stated she only reviewed the discharges. Interview on 8/24/23 at 4:15 p.m., with LVN/PPS Nurse regarding care plans. She stated Resident #1 had not had her care plan completed due to running behind schedule. She stated she is running behind on the completing skills need section for Resident #1's assessment. She stated Resident #1's pacemaker was not on the assessment if there was not an order. Interview on 8/24/23 at 4:45 p.m., with Unit Manager. Unit Manager stated she does not review the care plans. She stated the ADON advised her that she would review new admits. The unit manager stated she never viewed Resident #1's assessment. Interview on 8/24/23 at 5:00 p.m., with Administrator regarding care planning. The administrator stated he had not viewed Resident #1's care plan. He stated he has not seen an accuracy issue with care planning. He did say there are systems for readmitting a resident. He stated the resident is discussed during the morning meetings and at that time the discussion is to complete the necessary documents. A review of the undated facility's policy on Comprehensive assessments and the Care Delivery Process reveals comprehensive assessments conducted to assist in developing person-centered care plans. 676059 Page 2 of 4 676059 08/24/2023 Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who needs respiratory care was Residents Affected - Few provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for respiratory orders in that: The facility failed to set the flow rate at 2 liters of oxygen per the order for Resident #1. The facility failed to confirm the correct order for oxygen when her orders revealed 2L PRN and 2L continuously. The facility failed to provide Resident #1 with her oxygen while leaving facility to go to dialysis. These deficient practices could affect the residents who used oxygen and could result in residents receiving incorrect or inadequate respiratory support and could result in a decline in health. Findings Included: Electronic record review of Resident #1's face sheet revealed an [AGE] year-old who was initially admitted to the facility on [DATE] and re-admitted [DATE] with a diagnoses of End stage renal disease, essential (Primary) Hypertension, Gastrointestinal hemorrhage, anxiety disorder, major depressive disorder, presence of cardia pacemaker, (Congestive) heart failure. Record review of Resident #1's Last quarterly MDS dated [DATE] Section C revealed resident was not assessed for a BIMS score. Section O did not reveal: Oxygen in use while in the facility. Record review of Resident #1's physician's order dated 8/11/23 revealed O2 at 2 L/Minute via NC continuously, O2 at 2 L/Minute via NC PRN, O2 at 2 L/Minute via NC PRN and O2 sats Q Shift and PRN. Observation and interview on 8/22/23 at 11:15a.m., revealed Resident #1 was in bed alert and oriented. Her left upper arm had bandages resulting from dialysis appointment. Observation revealed she had a nasal cannula in one nostril and oxygen machine operating at 3 liters. Resident #1 was told the nasal cannula was on incorrectly as it was only in one nostril (right) and the other part was on the side of the right nostril. Resident #1 removed the cannula, looked at it, smiled and put it back on correctly. Resident #1 stated the oxygen made her feel better. Observation and interview on 8/22/23 at 11:45 a.m., revealed LVN #1 was in Resident #1's room, looked at the oxygen levels and exited the room without adjusting the oxygen levels. Observation and interview on 8/22/23 at 11:47 a.m., revealed LVN #2 in Resident #1's room. LVN #2 stated she works the 6am-2pm shift and conducted rounds this morning. LVN #2 said she checked Resident #1's nasal cannula only. She stated at 9am she checked her oxygen levels, which was at 97%. LVN #2 was asked what the level (black ball) on oxygen tank should be set at and she stated 2. LVN #2 was asked to explain why the oxygen level is set at 3 and she stated it could be due to resident lying flat down on 676059 Page 3 of 4 676059 08/24/2023 Park Manor of Westchase 11910 Richmond Ave Houston, TX 77082

F 0695 Level of Harm - Minimal harm or potential for actual harm her back. LVN #2 was asked about the dual orders for Resident #1's oxygen (PRN and Continuous). She stated the order is not unusual. She stated if Resident #1 experiences shortness of breath, then she puts on the nasal cannula oxygen, and if not, then she gets oxygen as needed. Residents Affected - Few Observation and interview on 8/22/23 at 11:55 a.m., LVN #1 returned to Resident #1's room. LVN #1 was asked if he knew what Resident #1's settings on her oxygen tank should be? LVN #1, said, oxygen settings should be set on 2. Investigator asked if he could show me the oxygen level and then stated the level is set at 3. LVN #1 immediately stated, this level is not right because it should have been set at 2. Investigator asked what was the doctor's order for Resident #1'soxygen level? He stated the doctor's orders was for PRN and Continuously. When asked what order he follows, LVN #1 stated, it depends, but if R #1 has trouble breathing, he will leave the oxygen on continuous. LVN #1 stated he checks the oxygen every shift. Interview on 8/22/23 at 1:00 p.m., with Administrative Assistance (AA) at DADC. Resident #1 has been going since 7/19/2021, three times weekly. Sometimes she has oxygen and sometimes she doesn't. The AA stated she was checked often and sometimes they must give her oxygen. She has been given two liters of oxygen since February 23rd, 2023. She stated she should be transported with oxygen. Stated it is probably because the nurse/facility did not give it to her. There are no notes. Stated R #1's last day at the facility was 8/21/23 at 3:15 p.m. Telephone interview on 8/22/23 at 1:15 with DN. Stated resident has always put her on oxygen. He stated Resident #1 always said she need oxygen. Stated Resident #1 was ambulatory transferred on stretcher. He stated Resident #1 did not appear to be in distress. He stated the EMS, and his facility has oxygen. Telephone interview on 8/23/23 at 2:13 p.m., with the physician revealed that any order with PRN and Continuously would be confusing to nursing staff. She stated she did not give a PRN order, only a Continuously order for Oxygen Level 2. An interview on 8/24/23 at 2:00 p.m. LVN #1 revealed he did not read the physician orders, however, documented that he acknowledged the orders. LVN #1 revealed he never discussed the orders with the doctor, he confirmed to making a mistake. Interview on 8/24/23 at 2:30 p.m., the DON revealed nursing staff should follow doctors' orders; however, even checking the MAR system for Resident #1, she did not catch the O2 orders. The DON stated these orders were an automated order for oxygen and the facility should call doctor to get a specific order. Interview on 8/24/23 at 2:45 p.m., the ADON revealed the nurses do the assessment, which are prepopulated when a resident is admitted or re-admitted . The ADON revealed she and the Unit Manager follow-up on all assessments, however, did not notice the physician orders that was noted by LVN #1. A review of the undated facility's policy on administering medications revealed medications shall be administered in a safe and timely manner, and as prescribed. 676059 Page 4 of 4