Conroe Health Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary treatment and services to promote Based on observation, interview and record review, the facility failed to provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 8 resident (Resident #57) reviewed for pressure sores. - The facility failed to provide repositioning and pillows/wedges to prevent Resident #57's development of a stage 2 pressure ulcer, ( an area of damage to the skin or underlying tissue that occurs when continuous pressure is placed on a particular part of the body that has skin loss to where the fat under the skin is visible but not bone, tendon or muscle), This failure could place resident at risk of development of new pressure sores, worsening of current sores, pain, suffering and infection. Finding Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for 1 (Saturday) of 6 mail delivery days reviewed for privacy. - The facility failed to ensure mail was delivered within 24 hours to residents on Saturdays. This failure could place residents at risk of not receiving mail in a timely manner that could result in a decline in the resident's well-being, quality of life and cause them to feel disconnected from family, friends, and current world issues.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess each resident's status for 2 of 8 resident (Resident #57 and Resident #68) reviewed for accuracy of assessments. - The facility failed to document Resident #57s lower extremity impairment in the resident's Quarterly MDS - The facility failed to document Resident #68's use of corrective lenses in the resident's quarterly MDS This failure could place residents at risk of inaccurate assessments, which could compromise their plan of care .

Inspectors wroteBased on observation, interview, and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which include measurable objectives and timeframes to meet resident's medical and nursing, needs for 3 of 7 residents (Residents #52, #59, #16) reviewed for comprehensive patient centered care plans. - The facility failed to develop a care plan that addressed Resident #52's dietary interventions to address low body weight and promote weight gain. - The facility failed to ensure Resident #16 and #59's care plans documented goals and interventions for hypertension. This failure could place residents at risk of weight loss and deteriorating health. This failure could place residents at risk of unsafe blood pressures and not receiving proper care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 8 residents (Resident #35 ) and 2 of 3 medication carts ( Front Hall nursing Cart & Station 1 Med Cart) reviewed for drug labeling and storage. - The facility failed to ensure the Front Hall Nursing Cart did not contain Resident #35's open and in-use bottle of Oxcarbazepine, a seizure medication, with no open date. - The facility failed to ensure the Station 1 Med Cart did not contain Aspirin with no visible expiration date. These failures could place residents at risk of adverse medication reactions and drug diversions.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for dietary services. The facility failed to ensure foods were sealed, labeled, or dated while in storage. This failure could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 8 residents (Resident #1) reviewed for dignity. - The facility failed to timely empty Resident #80's urinal timely resulting in it backflowing on the resident and the resident emptying it in the trash can at his bedside. This failure could place residents at risk of feeling uncomfortable and disrespected.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had a safe and homelike environment, including but not limited to receiving treatment and support for daily living safely for 1 of 8 residents reviewed (Resident #62) reviewed for a homelike environment. - The facility failed to ensure the bump rail located by window of Resident #62's room was attached to the wall without nails sticking out and the wall trim was not missing. This failure could place residents at risk of decreased feelings of self-worth, emotional destress, and physical injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, for 1 of 8 residents (Resident #67) reviewed for Quality of Care. -The facility failed to initiate the facility fall procedure after the state surveyor reported the suspect fall of Resident #67 to the DON. This failure could place residents at risk for pain and injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #42) reviewed for accidents and supervision. -The facility failed to provide adequate supervision to prevent, a bruise, as a result of an injury of unknown origin to Resident #42s sternum (the long flat bone located in the center of the chest). These failures could place residents at risk of minor and major injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administrating of all drugs and biologicals, to meet the needs of each resident for 1 of 1 Med Rooms (Station 1 Med Room) reviewed for pharmacy services. -The facility failed to ensure the Station 1 Medication Room did not contain expired oral Vancomycin (an antibiotic) for Resident #54 and Resident #200. This failure could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings Include: In observation and interview on 04/09/25 at 10:35 AM, inventory of the Station 1 Med Room with LVN E revealed - An open and in-use bottle of Vancomycin Oral solution for Resident #200 labeled Do Not Use After: 04/07/25 in the refrigerator. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents were free of significant medication error for two of seven residents (Resident #59 and #16) reviewed for significant medication errors. -The facility failed to ensure that MA B did not administer anti-hypertensive medications to Resident #59 and #16 based on BPs and pulse results obtained 1.5 hours prior to administration. This failure places residents at risk of discomfort or jeopardizing his/her health and safety.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 Med Rooms (Station 1 Med Room ) reviewed for environment. -The facility failed to ensure the Station 1 Med Room Insulin Refrigerator did not have mildew growing in it. These deficient practices could place residents at risk of injury from exposed nails and/or infections and adverse reactions from contaminatd medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 (CR #1) of 5 residents reviewed for respiratory care. - The facility failed to ensure consistent oxygen therapy was provided to CR #1 who was on hospice and a DNR. CR #1 was pronounced deceased at approximately 3:48 p.m. on [DATE]. -The facility failed to respond to CR #1's numerous requests for help for an approximate 2 ½ hour period. -The facility failed to monitor CR #1's oxygen administration via nasal cannula while she was in bed. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:21 p.m. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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) 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.