Health inspection·August 28, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate administration of all drugs and biologicals to meet the needs of each resident for two of six residents (Resident #1 and Resident #2) reviewed for medications. The facility failed to ensure all medications were administered according to facility procedure when nursing staff failed to document the administration of medications within the one-hour window according to facility policy. This failure could place residents at risk for not receiving the therapeutic benefits from medications. Findings included: Resident #1 Review of a face sheet showed Resident #1 was an [AGE] year-old female admitted on [DATE] with diagnoses of Essential (Primary) Hypertension (High Blood Pressure), Epilepsy (a condition which could cause seizures), Transient Cerebral ischemic attach (Stroke), and Atherosclerotic heart disease of native coronary artery without angina pectoris (A buildup of plaque inside the coronary artery, the main artery which supplies blood to the heart, which can cause the arteries to narrow, blocking blood flow to the heart). Review of consolidated physician order for August 2023 showed Resident #1 was to receive Levetiracetam 750 mg twice and day, Carbamazepine 200 mg twice daily, and Vimpat 50 mg twice daily for Epilepsy. Potassium chloride 10 mg, one a day and Carvedilol 6.25 mg twice daily, Plavix 75 mg one a day, and Eliquis 5 mg twice a day for heart disease, Aspirin 81 mg once a day for cerebral infarction, and Amlodipine 10 mg once a day for hypertension. Review of the medication administration records dated 08/25/23 showed at 7:42 a.m., Resident #1 received Aspirin 81 mg. At 8:59 a.m. received Carbamazepine 200 mg, Levetiracetam 750 mg, Eliquis 5 mg, Vimpat 50 mg, Plavix 75 mg, and Potassium chloride 10 mg. At 9:46 a.m. Resident #1 received Amlodipine 10 mg and Carvedilol 6.25 mg. According to the MAR these medications were to be given at 8:00 a.m. During an interview on 08/25/23 at 12:15 p.m., Resident #1 said one day a few weeks ago, she did not get her morning meds until about noon. Resident #1, said she told the DON about it, and wondered Page 1 of 3 455834 455834 08/28/2023 Avir at Athens 150 Gibson Rd Athens, TX 75751

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some when she would be able to get her noon meds since she was just now getting her morning meds and it was almost noon. Resident #1, said the DON told her she would have to wait at least 4 hours to receive her next dose, because she could not have them so close together. Resident #1 said she was concerned because she receives blood pressure medication, and she should not wait hours for the medication to be given. Resident #1 said the medication aide who was late giving the medication was an agency staff and she did not know her name. Resident #1 said she had not seen the med aide at the facility since that day. Resident #2 Review of a face sheet showed Resident #2 was a [AGE] year-old female admitted on [DATE] with diagnoses of Hypertension, Dysphagia following cerebral infarction (Stroke), and Atherosclerosis heart disease of native artery without angina. Review of the consolidated physician orders for August 2023 showed Resident #2 was prescribed Lisinopril 20 mg and amlodipine 5 mg once a day for hypertension, and Aspirin 81 mg tablet one a day for Atherosclerosis heart disease of native artery without angina Review of the MAR for August 2023 for Resident #2 showed on 08/04/23, 08/05/23, 08/07/23, 08/11/23, 08/14/23, 08/17/23, 08/18/23, and 08/19/23 there was late administration with comments of charted late for aspirin 81 mg. On 08/04/23, 08/05/23. 08/07/23. 08/08/23, 08/09/23, 08/11/23, 08/14/23. 08/17/23. 08/18/23, 08/19/23, 08/21/23, 08/23/23 there was late administration with comments of charted late for amlodipine 5 mg. On 08/04/23, 08/05/23, 0807/23, 0809/23, 08/11/23, 08/14/23, 08/17/23, 08/18/23, 08/19/23, 0821/23, and 0/823/23 for Lisinopril 20 mg medications were documented late. During an interview on 08/25/23 at 12:15 p.m., Resident #2 said most of the time she receives her medication timely, but there had been times when she received her medication late. Resident #2 said she had not had any adverse effects from getting her medications late. During an interview on 08/28/23 at 9:20 a.m. the DON said she does not know and cannot tell the difference from when a medication was given late or when it was just charted late by looking at the electronic MAR. The DON said nurses document the reason a medication was given late in the nurse progress notes. The DON said medications aides do not have the ability to chart in progress notes why a medication was given late. The DON said the facility had been using agency staff and when an agency staff failed to document medication administration timely the only recourse, she had was to notify the agency that the nurse or Medication Aide cannot return to the facility. DON said that was the only disciplinary acting she has in dealing with agency staff. The DON said she remembered Resident #1 talking to her about getting her medication late. She said she told Resident #1 the medication could not be given too close together and they would have to wait at least four hours before the next dose could be administered. The DON said the medication aide who failed to administer the medications to Resident #1 was an agency staff. The DON said the agency was notified and the medication aide was not allowed to return to work at the facility. The DON said there was no adverse effect to Resident #1 not receiving the medication. During observation and interview on 08/28/23 at 8:15 a.m. LVN A was observed passing medications. LVN A was observed taking a Resident's blood pressure with a reading of 111/64. LVN A was observed writing the blood pressure reading on a piece of paper on the medication cart. LVN A said to ensure residents receive their medication timely, sometimes she would write it down on a piece of paper and enter it into the e-MAR later after she had passed all the medications. LVN A said just because there 455834 Page 2 of 3 455834 08/28/2023 Avir at Athens 150 Gibson Rd Athens, TX 75751

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was a late entry on the e-mar, does not mean the medication was given late. LVN A said it just showed the documentation was done after the time the medication was due and not that the medication was administered late. LVN A said the 8:00 AM medications can be given anytime between 7:00 AM and 9:00 AM and would not be late. LVN said if a medication was physically given outside those time frames, the nurse is to enter a reason in the nurse's progress notes as to why the medication was given late. LVN said had completed the morning medication pass for today and all medications had been given. During an interview on 08/28/23 at 11:15 a.m., LVN B said she was not aware of resident receiving their medications late. LVN B said sometimes documentation was entered into the e-MAR after the medication was given and it may be after the scheduled time and the system shows it as late. LVN B said if a medication was given late, the nurse should chart the reason for the medication being given late. LVN B said it could be because the resident was out of the facility at the time, in an activity, or sleeping and has asked not to be disturbed. LVN B said she was not aware of any adverse effects to a resident due to not receiving their medication timely. Review of the facility policy for medication administration dated 08/2020, showed POLICY: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. PROCEDURE: 1 Medications are prepared, administered, and recorded only by licensed nursing, certified medication aides or other professional authorized by state laws and regulations to administer medications.8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician. The resident's MAR is initialed by the person administering a medication. 455834 Page 3 of 3