Health inspection·February 13, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Resident #1) of 5 residents reviewed for informed consent for treatment options. Residents Affected - Some The facility failed to: 1. obtain a signed informed consent for the use of Seroquel for Resident #1 by her MPOA 2. obtain a signed informed consent for the use of ABH gel for Resident #1 by her MPOA This failure could affect all residents by placing them at risk of receiving psychotropic medications without informed consent which could cause decrease quality of life and increase the risk of injury and violate the rights of residents to make informed decisions related to care. Findings included: Record review of Resident #1's undated face sheet, printed on 02/10/24, revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, anxiety and dementia. It further revealed that her emergency contact and Responsible Party was FAM. Record review of Resident #1's 01/06/24 quarterly MDS revealed a BIMS of 3, which was indicative of severely impaired cognition. It further revealed her primary language was Spanish and she was usually understood and usually understood others. It revealed that she had no hallucinations nor did she have delusions that would be potential indicators of psychosis . In an interview on 02/10/24 at 2:00 pm with FAM, she stated that she was told the doctor wanted to start Resident #1 on Seroquel, but FAM wanted to research the medication before signing consent. She stated she never signed consent for the use of Seroquel for Resident #1. She also stated she never consented to use of ABH gel (Ativan, Benadryl, Haldol). In an interview on 02/11/24 at 2:45 pm with MD she stated that she had a duty to treat Resident #1 and had verbal consent for the use of seroquel by FAM and the medication was put on hold when the consent was not signed after several days. Record review of Resident #1's Orders revealed an order for QUEtiapine Fumarate (Seroquel) Tablet 25 MG Give 0.5 tablet Page 1 of 5 455771 455771 02/13/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some by mouth at bedtime for behavioral disturbance; the order was started 01/29/24 at 8:00 pm. Further review revealed an order for Lorazepam-Diphenhydramine-Haloperidol mg (ABH Gel); Apply to skin topically every 2 hours as needed for agitation for 14 Days, order started 01/15/24. Record review of Resident #1's MAR, January/February of 2024, revealed she was administered Seroquel on the following dates; 1/29/24 1/30/24 1/31/24 2/1/24 2/2/24 2/3/24 2/4/24 Further review revealed the medication was marked as on hold starting 02/05/24. Further review of Resident #1's MAR, January of 2024, revealed she was administered ABH gel on the following dates: 01/15/24 01/17/24 01/19/24 01/20/24 Record review of Resident #1's progress notes revealed a note by the MD on 01/29/24 at 4:26 pm that reflected that FAM was agreeable to start quetiapine (Seroquel). A progress note dated 02/05/24 at 8:47 am stated that FAM had not signed consent so medication was not given. Record review revealed a consent for Seroquel that was not signed by FAM. Record review revealed no signed consent for ABH gel. 455771 Page 2 of 5 455771 02/13/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for one of one (Resident #1) of two residents reviewed for Comprehensive Care Plans, in that: The facility failed to schedule a care plan meeting with FAM and Resident #1 that involved a multidisciplinary team and instead documented a phone call between FAM and the Social Worker as the care plan meeting. This failure could place residents at risk of not receiving the highest practicable interventions, treatments and care by not involving the resident and FAM (MPOA) of a care plan meeting. Findings included: Record review of Resident #1's undated face sheet, printed on 02/10/24, revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, anxiety and dementia. It further revealed that her emergency contact and Responsible Party was FAM. Record review of Resident #1's 01/06/24 quarterly MDS revealed a BIMS of 3, which was indicative of severely impaired cognition. It further revealed her primary language was Spanish and she was usually understood and usually understood others. It revealed that she had no hallucinations nor did she have delusions that would be potential indicators of psychosis. Record review of the assessment titled Multidisciplinary Care Conference - V2 with an effective date of 12/28/23 revealed the meeting was 12/28/23 at 11:40 am and it was marked as the quarterly care conference. The only staff marked in attendance was the social worker. None of the l7 areas to be addressed per the form were marked as addressed, all were left blank. Under summarize discussion of the care plan conference there was a note stating FAM had a question about Resident #1's fall and the SW encouraged her to get with nursing about questions related to that. The SW said she was going to activities and the SW was making a referral to dental. It was further marked that the family member attended by phone and the only staff member who signed was SW. In an interview on 02/10/24 at 2:00 pm with FAM she stated that she had never attended a care plan meeting. She said she had called near the end of December (2023) about her Resident #1 having a fall that required stitches, but nothing else was discussed. She was not told in advance about a care plan meeting so she could attend . She also said her mother was not present on the phone call with SW. In an interview on 02/11/24 at 4:00 pm with the DON, she stated that a care plan meeting should be scheduled and include staff from all departments, the resident and the resident representative . 455771 Page 3 of 5 455771 02/13/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #1) of 5 residents reviewed for psychotropic drug use. The facility failed to: 1. ensure Resident #1 was prescribed Seroquel and ABH gel for a specific diagnosis and instead prescribed it for behavioral disturbance at bedtime This failure could affect all residents by placing them at risk of receiving psychotropic medications without a specific diagnosis and rather being prescribed psychotropic medication for behavior; this could cause decrease quality of life and increase the risk of injury. Findings included: Record review of Resident #1's undated face sheet, printed on 02/10/24, revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, anxiety and dementia. It further revealed that her emergency contact and Responsible Party was FAM. Record review of Resident #1's 01/06/24 quarterly MDS revealed a BIMS of 3, which was indicative of severely impaired cognition. It further revealed her primary language was Spanish and she was usually understood and usually understood others. It revealed that she had no hallucinations nor did she have delusions that would be potential indicators of psychosis . In an interview on 02/10/24 at 2:00 pm with FAM, she stated that she was told the doctor wanted to start Resident #1 on Seroquel, but FAM wanted to research the medication before the Seroquel was administered to Resident #1. In an interview on 02/11/24 at 2:45 pm with MD stated she had a duty to treat Resident #1's behaviors while awaiting signed consent from FAM. Record review of Resident #1's Orders revealed an order for QUEtiapine Fumarate (Seroquel) Tablet 25 MG Give 0.5 tablet by mouth at bedtime for behavioral disturbance; the order was started 01/29/24 at 8:00 pm. Further review revealed an order for Lorazepam-Diphenhydramine-Haloperidol mg (ABH Gel); Apply to skin topically every 2 hours as needed for agitation for 14 Days, order started 01/15/24. Record review of Resident #1's MAR, January/February of 2024, revealed she was administered Seroquel on the following dates; 1/29/24 455771 Page 4 of 5 455771 02/13/2024 Hearthstone Nursing and Rehabilitation 401 Oakwood Blvd Round Rock, TX 78681

F 0758 1/30/24 Level of Harm - Minimal harm or potential for actual harm 1/31/24 2/1/24 Residents Affected - Few 2/2/24 2/3/24 2/4/24 Further review revealed the medication was marked as on hold starting 02/05/24. Further review of Resident #1's MAR, January of 2024, revealed she was administered ABH gel on the following dates: 01/15/24 01/17/24 01/19/24 01/20/24 Record review of Resident #1's diagnoses list, on 02/10/24, revealed no diagnosis of psychosis, schizophrenia nor bipolar disorder, and her only mental health diagnoses were anxiety, depression, and insomnia (she also has a diagnosis of dementia). Record review of Resident #1's progress notes revealed a note by the MD on 01/29/24 at 4:26 pm that reflected that FAM was agreeable to start quetiapine (Seroquel). A progress note dated 02/05/24 at 8:47 am stated that FAM had not signed consent so medication was not given. 455771 Page 5 of 5