Health inspection·May 28, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure assessment accurately reflects the resident's status for 1 (Resident #9) of 13 residents reviewed for accuracy of assessments, in that Residents Affected - Few -The facility failed to ensure Resident #9's Quarterly MDS assessment accurately reflected her bowel and bladder status. This failure could place residents at risk for inadequate care, diminished quality of life and decline in health. Findings include: Record review of Resident #9's admission Record revealed she was an [AGE] year old female that readmitted to the facility on [DATE] with diagnoses of hyperlipidemia (high cholesterol), dysphagia (difficulty or discomfort in swallowing), bipolar disorder (a condition associated with episodes of mood swings ranging from depressive lows and manic highs), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures and can be genetic or as a result of injury). Her BIMS score was 15 out of 15 indicating she had no cognitive impairment. Record review of Resident #9's Quarterly MDS assessment on 5/16/24 at 12:15 pm dated 4/12/24 revealed in section GG Functional Abilities and Goals Resident #9 was coded as follows: C. Toileting Hygiene .88. not attempted due to medical condition or safety concern. Section H. Bladder and Bowel, read in part, always incontinent of urine, and always incontinent of bowel. It was signed as completed by MDS Coordinator on 4/17/24 and DON on 4/18/24. Record review and interview with MDS Coordinator on 5/15/24 at 12:30pm who said that she did not know why Resident #9's Q MDS dated [DATE] was coded as not assessed in section GG for toileting hygiene. While speaking with surveyor and continuing to review Resident #9's EMR, the MDS Coordinator said she would modify Resident #9's Q MDS dated [DATE] because it was incorrect for bowel and bladder coding. The MDS Coordinator said she did not know exactly why she reviewed Resident #9's toileting, which had always been coded as dependent, but for some reason it was coded as not assessed in error. The MDS Coordinator said that she completed the MDS for Resident #9 and did not know how the error in coding happened. The MDS Coordinator said Resident #9 had been incontinent of bowel and bladder and dependent for toileting hygiene from her 12/16/2016 admission. The MDS Coordinator said that she used the RAI manual as her policy and procedure for completing the resident MDS assessments. Record review of Resident #9's modified Quarterly MDS on 5/16/24 at 12:16pm revealed in section GG Functional Abilities and Goals Resident #9 was coded as follows: C. Toileting Hygiene .01. Page 1 of 8 455477 455477 05/28/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0641 Level of Harm - Minimal harm or potential for actual harm Dependent. Helper does all of the effort or the assistance of 2 or more helpers is required for resident to complete the activity. Section H. Bladder and Bowel, read in part, always incontinent of urine, and always incontinent of bowel. Section X. Correction revealed: Reason for Modification .B. Data entry error. Section Z Assessment Administration Signature of Persons Completing the Assessment of Entry/Death Reporting , was signed by MD Coordinator and DON with Date Section Completed 5/15/24. Residents Affected - Few Interview with DON on 5/16/24 at 1:15pm she said she was not familiar with Resident #9's bowel and bladder status and would have to look in resident's medical record. The DON said that she signed Resident #9's Q MDS dated [DATE] because she signs the MDS assessments that were completed at the facility. The DON said she signed the modified Q MDS for Resident #9 on 5/15/24 after the error was identified by the MDS Coordinator on 5/15/24 after speaking with surveyor. Record review of CMS's RAI Version 3.0 Manual dated October 2023, pages 1-7 revealed the following The RAI process had multiple regulatory requirements . (1) the assessment accurately reflects the resident's status. 455477 Page 2 of 8 455477 05/28/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0759 Ensure medication error rates are not 5 percent or greater. 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 medication error rate of less than 5%. There were 2 errors out of 30 opportunities which resulted in a 6% error rate involving 2 of 3 residents (Resident #12, and Resident #20) and 1 of 2 employees (MA A) observed during medication administration reviewed for medication error , in that: Residents Affected - Few -MA A omitted Resident #12's Bismuth/[NAME] pectate anti diarrheal medication. -MA A gave Resident #20 an incorrect dose of her nasal spray. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes. The findings were: Resident #12 Record review of Resident #12's admission Record revealed she was a [AGE] year old female who admitted to the facility on [DATE] with the following diagnoses: diarrhea (a condition of having loose, watery stools, three or more times in a day, or more frequently than usual for the individual), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and often with personality changes and anxiety (an uncontrollable feeling of worry, fear or uneasiness and can be mild or severe and can be experienced through thoughts, feelings and physical sensations). Record review of Resident #12's physician order summary report dated active as of 5/15/24 had the following medication order: [NAME] pectate oral tablet 262 mg (Bismuth) give 1 tablet by mouth one time a day related to diarrhea and had an order date 3/21/24 and start date 4/2/24. There was no end date. Observation and interview of Resident #12's medication administration pass performed by MA A on 5/14/24 at 9:27 am. MA A explained to Resident #12 that she was going to give her morning medication. MA A prepared Resident #12's medications after assessing the residents' vital signs. MA A did not have Resident #12's [NAME] pectate and said it had been ordered but had not been delivered yet, so she was unable to give that medication during the medication administration. MA A did not look for the medication in any other location and did not ask any other staff member for assistance in locating the medication. Resident #12's [NAME] pectate oral tablet 262 mg (Bismuth) give 1 tablet by mouth one time a day was not given. Record review of Resident #12's MAR dated 5/1/2024-5/31/2024 revealed staff documented the number 9 on May 12 through May 14th for the resident's [NAME] pectate oral tablet 262 mg (Bismuth) give 1 tablet by mouth one time a day related to diarrhea. Continued review of the MAR chart codes reflected the number 9=Other/See Nurse Notes. There were no other nurse notes and per MAR documentation the resident had not received the medication from 5/12/24 through 5/14/24. Record review on 5/14/24 at 10:32 am of Resident #12's MAR dated 5/1/2024-5/31/2024 revealed MA A 455477 Page 3 of 8 455477 05/28/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0759 documented 9=Other/See Nurse Notes. Level of Harm - Minimal harm or potential for actual harm Resident #20 Residents Affected - Few Record review of Resident #20's admission Record revealed she was an [AGE] year old female who admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (also known as senile dementia a progressive disease that destroys memory and other important mental functions including thinking and behaviors), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #20's physician order summary report dated active as of 5/15/24 had the following medication order: Flonase allergy relief nasal suspension 50 MCG/ACT (nasal) 1 spray in both nostrils one time a day and had an order date 8/20/23 and start date 8/21/23. There was no end date. During an observation and interview on 5/14/24 at 9:40 am MA A administered per medication package, Flonase Nasal Spray suspension 50 MCG/ACT 2 sprays in both nostrils daily X 14 days . MA A said Resident #20 received 2 sprays in each nostril and that she believed the order had recently been updated. Record review of Resident #20's MAR dated 5/1/2024 through 5/31/2024 revealed MA A documented that she had given Flonase allergy relief nasal suspension 50 MCG/ACT (nasal) 1 spray in both nostrils one time a day in the morning on 5/14/24. Interview with DON on 5/15/24 at 10:33 am who said that she also believed Resident #20's nasal spray order had been changed recently but that MA A should have administered what the physician order said at the time of the medication administration pass. The DON said that she was responsible for and over saw the training of all staff administering medications and that staff had been trained on medication administration. DON did not comment on why Resident #12's [NAME] pectate was not available during the administration and said she would follow up on both errors. Record review of a facility provided policy and procedure titled Administering Medication and dated revised April 2019, read in part: 4. Medications are administered in accordance with prescribers' orders .10. The individual administering medication checks the label THREE (3) times to verify the right resident, right medication, right dosage .before giving the medications. 455477 Page 4 of 8 455477 05/28/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ACT Actuation Residents Affected - Some BIMS - Brief Interview for Mental Status EMR - Electronic Medical Record DON - Director of Nursing LVN - License Vocational Nurse MA - Medication Aide MAR - Medication Administration Record MCG - Microgram MDS - Minimum Data Set Q - Quarterly RAI - =Resident Assessment Instrument S/S= E Surveyor Name(s): [NAME] Immediate Supervisor: [NAME] Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 1 of 3 residents (Resident #23) reviewed for unnecessary medications. -Facility failed to give Resident #23's Midodrine 10 mg medication as ordered by the physician. -The facility failed to check the resident's SBP level before administering Resident #23 her Midodrine 10mg medication. This deficient practice could place residents in the facility at risk of having the use of an unnecessary drug without adequate indications for its use, and a decline in their health. Findings include: Record review of Resident #23's face sheet dated 5/15/2024 reflected Resident #23 was a [AGE] year-old woman who was admitted to the facility on [DATE]. Her diagnoses included Paraplegia (paralysis that affects your legs, but not your arms), pressure ulcer of stage 4, post-traumatic stress disorder (an anxiety disorder that can come from a traumatic event), cellulitis of unspecified part of limb 455477 Page 5 of 8 455477 05/28/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (a common and potentially serious bacterial skin infection) and essential hypertension (a type of high blood pressure that develops gradually over time and has no identifiable cause). Record review of Resident #23's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 15 indicating no impaired cognition. The resident required extensive assistance with one person's physical assist with bed mobility, total dependence and two person's physical assist for transfer, supervision, and setup for eating, and extensive assistance and two person's assists for toilet use. Observation and interview on 5/28/2024 at 12:15p.m. with Resident #23, revealed her in a wheelchair, wheeling herself towards her room. She said she took Midodrine medication for low blood pressure and she said so far it had been working out just fine. She said the medication brings her blood pressure up, but it would go low again. She said she had not had any problems are symptoms related to her Midodrine medication. She said staff only gave her the medication when and if her blood pressure was 110 or less. She said they have not given it to her when her blood pressure was higher than 110. Record review Resident #23's Care Plan initiated on 06/7/23 revealed, Focus: Hypertension, Medication: Midodrine, Intervention: Check B/P TID and administer Midodrine as directed. Give medication as ordered. Monitor for side effects and effectiveness. Record review of Resident #23's MED and MAR Records revealed, Check BP, give Midodrine 10 mg for SBP less 110, three times a day related to hypertension, unspecified give Midodrine 10 mg for SBP less than 110 -D/C Date 4/2/2024. Resident was given Midodrine medication when her SBP was higher than 110 on 3/1/2024 (124/68), 3/2/2024 (124/65), 3/3/2024 (112/58), 3/5/2024 (117/62), 3/7/2024 (117/67), 3/8/2024 (114/55), 3/9/2024 (121/59), 3/10/2024 (113/54) at 9:00am and (113/54) at 9:00p.m., 3/12/2024 (129/68), 3/14/2024 (122/64) at 9:00a.m. and (114/45) at 9:00p.m., 3/16/2024 (144/80) at 9:00am and (153/73) at 2:00p.m., 3/17/2024 (135/73) at 9:00a.m. and (116/61) at 2:00p.m. and (115/56) at 9:00p.m., 3/18/2024 (121/56), 3/19/2024 (125/70) at 9:00a.m., and (133/70) at 2:00p.m. and 126/64 at 9:00p.m., 3/22/2024 (117/59), 3/23/2024 (112/58), 3/24/2024 (135/71) at 9:00a.m. and (127/74) at 9:00p.m., 3/28/2024 (120/62), and 3/29/2024 (118/56). 4/2/2024 (113/76), 4/6/2024 (129/71), 4/7/2024 126/71) at 2:00p.m. and (126/71) at 9:00p.m., 4/9/2024 (121/66) at 2:00p.m., 4/11/2024 (121/73) at 9:00a.m., 4/15/2024 (112/69) at 2:00p.m., 4/20/2024 (125/78) at 2:00p.m., 4/21/2024 (117/60) at 2:00p.m., 4/23/2024 (165/69) at 9:00p.m., 4/24/204 (137/89) at 9:00a.m., 4/25/2024 (116/65) at 9:00a.m., 4/27/2024 (115/56) at 9:00p.m., 4/28/2024 (122/60) at 9;00p.m., 4/29/2024 (127/780 at 9:00a.m. and (127/78) at 9:00p.m., 4/30/2024 (118/60) at 9:00p.m. Observation and interview on 5/15/2024 at 3:30 PM with the MDS Coordinator revealed her making changes to the dates of Resident #23's orders after she was asked to print out the orders to verify the dates. She said she wanted to update it so that it could be corrected after it was brought to her attention that the nurses were giving the resident's medication against the physician orders. She said she spoke to the physician and was told she could discontinue the medication. Interview on 5/15/2024 at 3:58p.m. with the DON and she said Resident #23's blood pressure was taken every day and if it was indicated they did not give it to her. She said regarding the Midodrine medication, the Administrator was supposed to follow up on it . She said she made sure errors will not happen by running audits and pulling the MARS. She said she has talked to the CMAs and in-serviced them once before for giving Resident #23 her Midodrine medication when her blood pressure was above 110. She said she was not sure why there are so many errors each month. She said she cannot explain what happened. She said giving Resident #23 her Midodrine medication when her SBP was above 110, 455477 Page 6 of 8 455477 05/28/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0842 could elevate her blood pressure even more. Level of Harm - Minimal harm or potential for actual harm Interview on 5/15/2024 at 4:23p.m. with the ADON and she said she spoke to nursing staff about Resident #23's Midodrine medication and she said they knew if her SBP was over 110 not to give it to her and sign it in the computer. She said the Midodrine medication was routine. She said giving the resident medication against the physician's orders could put the resident in a hypertension crisis. She said she tried on 4/2/2024 to correct the Midodrine medication and was not successful. Residents Affected - Some A follow-up interview on 5/28/2024 at 12:52p.m. with the ADON, and said she was aware of the problem from the pharmacist's consultant, and she did not remember the date. She said the way the Midodrine order was put in the system initially was confusing to the CMAs. She said it seemed that they were documenting that they had given it when they were not giving it and vice versa. She said in the CMA's documentation, it looked like had not given Resident #23 her medication and they had given it to her during that time. She said initially it was all on one order . She said they checked Resident #23's BP three times a day and administered 10 mg if systolic BP was less than 110. She said the Pharmacist recommend that they change it so that they could split the order . She said the documentation did not show that they did it correctly. She said changing the order still did not work . She said she started Resident #23 on Midodrine when her blood pressure was low. She said it appears that it was given at the wrong times but when you talk to the CMAs, they would swear that they just wrote it down incorrectly. Interview on 5/15/2024 at 5:00p.m. with CMA A and she said she knew better than to give Resident #23 her Midodrine medication if her blood sugar was high. She said if it was less than 110, she could receive her medication. She said she was in-served this year because someone was in trouble about giving the medication while Resident #23's blood pressure was high. She said she knew what to give the resident regarding her medication because it was on the MAR's and staff can see. She said if you give Resident #23 her medication when her blood pressure is over 110, it can cause her blood pressure to go higher. An interview on 5/28/2024 at 1:07p.m. with CMA B, and she said hypertension was high blood pressure, and hypotension was low blood pressure. She said she had been working at the facility since 12/4/2023. She said she started as an CNA and became a CMA on 5/10/2024. She said she had currently passed out medication to Resident #23, but she did not pass out the Midodrine medication. An interview on 5/28/2024 at 1:16p.m. with LVN A, and said hypertension brings down the blood pressure, and hypotension is when your blood pressure is low, and it helps to bring it up. She said she had passed out Resident #23's Midodrine medication in the past. She said she gave it to her because most of the time she had low blood pressure. She said she just started passing out medication to Resident #23 on Friday. She said she checked Resident #23's blood pressure and if it was within the parameters, she would administer the medication to her. An interview on 5/28/2024 at 1:28p.m. with CMA C, and she said hypertension was high blood pressure, and hypotension was low blood pressure. She said the Midodrine was for when Resident #23's blood pressure was running low. She said she took Resident #23's blood pressure and she know for a fact that she accidently documented that she administered the medication even though she did not administer the medication when Resident #23's blood pressure was high. She said she had to ask the nurse to change it, but it was never done. She said the nurse had to strike it out, but it was never done. She said the Administrator came to her about another patient who had a similar situation as Resident #23. She said she always checked the medication and was not sure why it was showing up on the MARS that 455477 Page 7 of 8 455477 05/28/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she gave the Midodrine medication to the resident when her blood pressure was high. She said she never administered medication to a resident who was not supposed to receive the medication. She said there were times when she did not go to the administration tab after she has clicked yes, and when she put it into the vitals tab, it would show that it was administered although it had not been administered to the resident. Record Review of the facility's policy titled Administering Medication, revised on 12/2019 read in part . Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 455477 Page 8 of 8