Health inspection·August 21, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for one (Residents #1) of six residents reviewed for clinical records. RN A and LVN B failed to document on Resident #1's August 2023 Medication Administration Record accurate medication times of her insulin on the following dates: 08/01/23, 08/02/3, 08/05/23, 08/06/23,08/07/23, 08/08/23,08/10/23, 08/11/23, 08/12/23,08/13/23, 08/14/23, and 08/15/23. This failure could place residents at risk for inaccurately documented medical records. Findings included: Review of Resident #1's Face Sheet, dated 08/21/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses cognitive communication deficit and type 1 diabetes. Review of Resident #1's Quarterly MDS assessment, dated 07/21/23, reflected Resident #1 had a BIMs score of 15 indicating she was cognitively intact. She had diagnoses of stroke, diabetes, hyperglycemia (high blood sugar), and cognitive communication deficit. Review of Resident #1's Care Plan dated 08/21/23 reflected she had diabetes Mellitus and would have no complicates related to diabetes through target date 09/03/23. Review of Resident #1's Physician's Orders dated 08/21/23 revealed the following physician's orders: Insulin Glargine inject 25 units subcutaneously in the morning scheduled at 08:00 AM for Diabetes Mellitus, order dated 06/11/23; discontinue date 08/06/23. Insulin Aspart inject 6 units subcutaneously one time a day before meals with lunch scheduled at 12:00 PM related to hyperglycemia, order date 03/11/23. Insulin Aspart inject 4 units subcutaneously one time a day before meals with dinner scheduled at 05:00 PM related to hyperglycemia, order date 03/11/23. Insulin Aspart inject as per sliding scaled if 151-200=2units; 201-250=4 units; 251-300=6 units; Page 1 of 5 455904 455904 08/21/2023 Rowlett Health and Rehabilitation Center 9300 Lakeview Pkwy Rowlett, TX 75088

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 301-350=8 units; 351-999=10 units; subcutaneously before meals scheduled at 06:30 AM, 11:30 AM, 04:30 PM, and at bed time scheduled at 09:00 PM related to type 1 Diabetes Mellitus order date 03/11/23. Review of Resident #1's facility Medication Administration Records for August 2023 reflected: RN A documented Resident #1's scheduled 08:00 AM dose of Insulin Glargine 25 units was administered on 08/06/23 at 09:24 AM. RN A documented Resident #1's scheduled 12:00 PM dose of Insulin Apart 4 units was administered on 08/13/23 at 02:03 PM. RN A documented Resident #1's scheduled 06:30 AM dose of Insulin Aspart per sliding scale was administered on 08/05/23 at 07:38 AM, the scheduled 08/12/23 dose was administered at 08:19 AM, and the scheduled 08/06/23 dose was administered at 09:24 AM; the scheduled 11:30 AM dose was administered at 12:52 PM. LVN B documented Resident #1's scheduled 05:00 PM dose of Inulin Apart 4 units before dinner was administered on 08/01/23 at 10:21 PM, the scheduled 08/02/23 dose was administered at 06:48 PM, the scheduled 08/07/23 dose was administered at 06:49 PM, the scheduled 08/08/23 dose was administered at 09:52 PM, the scheduled 08/10/23 dose was administered at 06:56 PM, the scheduled 08/11/23 dose was administered at 10:03 PM. LVN B documented Resident # 1's scheduled 04:30 PM dose of Insulin Aspart per sliding scale was administered on 08/08/23 at 09:51 PM, the scheduled 08/09/23 dose was administered at 06:07 PM, the scheduled 08/11/23 dose was administered at 10:02 PM, the scheduled 08/14/23 dose was administered at 06:05 PM, and the scheduled 08/15/23 dose was administered at 06:21 PM; the scheduled dose at 09:00 PM was administered at 10:30 PM. In an interview on 08/18/23 at 10:02 AM Resident #1 stated she received her insulins sometimes before, at times after a meal, and bedtime. Resident #1 stated the times she was served her meals varied and facility staff were to provide her insulins right before she ate a meal. Resident #1 stated she explained to staff her insulins should be given right before she ate which never happened. In an interview on 08/21/23 at 08:21 AM RN A stated she was aware of Resident #1's scheduled medication administration times by checking the resident's medication administration record. RN A stated with Resident #1's insulin she had to provide it to the resident at the specified time the medication administration record indicated it was due. RN A stated he had to administer Resident #1's insulin within 15 minutes before she received her meals. RN A stated immediately after she administered insulin, she should have documented on the resident's medical administration record it was given. RN A stated at times she had documented the administration of Resident #1's insulin 30 minutes beyond its scheduled time as she had to wait on her meal to be ready. RN A stated without looking at the specific August 2023 medication administration record for Resident #1 she could not remember the times she charted Resident #'1s administration of insulin. RNA stated she had administered Resident #1's insulins timely but documented the administration times late on her medication administration record. RN A stated at times if she had charted beyond the 30 minutes after a scheduled dose of insulin was due for Resident #1 she could have been called away to do something and documented the insulin as administered later in her shift because she was busy. RN A stated she had administered medication late to Resident #1 and the risk of documenting Resident #1's insulin administration late would be it 455904 Page 2 of 5 455904 08/21/2023 Rowlett Health and Rehabilitation Center 9300 Lakeview Pkwy Rowlett, TX 75088

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some could be considered a medication error because the resident's medication needed to be administered per physician's orders. In an interview on 08/21/23 at 08:41 AM LVN B stated she was aware of when a resident's insulin was to be administered by checking the medication administration record. LVN B stated she was to provide a resident's insulin 10 minutes before a meal was served. LVN B stated she had administered Resident #1's insulin each time she worked with the resident within the scheduled time as indicated on the resident's medication administration record, she then wrote the time she administered the medication on a paper and documented it in the electronic medication administration record later in her shift. LVN B stated in those instances where she documented in Resident #1's electronic medical record late administration times of insulin she had been called away from the task of documentation for reasons like a resident had fallen, she had an admission, or an incident had occurred keeping her from documenting in real time. LVN B stated the risk of late documentation would indicate she had not administered Resident #1's medication as physician ordered. In an interview on 08/21/23 at 09:57 AM Resident #1's attending physician stated facility staff should instantly document the administration of Resident #1's medication in her medication record as they had given her scheduled doses of insulin. He stated he had no indication staff were not administering Resident #1's insulins timely but discussed with the facility as part of the Quality Assurance meeting the issue of staff completing their medication pass for Resident #1 and then documenting the administration later in the shift. In an interview on 08/21/23 at 12:00 PM the DON stated when staff administered Resident #1's insulin they should immediately document in the resident's electronic medication record that the task had been completed. The DON stated he had encountered times in which Resident #1's insulin administration had not been documented timely by staff. The DON stated there were instances in which nursing staff were delayed from documenting real time administration of insulins because they may have to retrieve a meal from the dining room. The DON stated RN A and LVN B should have documented the administration of Resident #1's insulin immediately after providing it to her and not later in their shift. The DON stated in some instances nursing staff failed to document in the moment when they had administered a resident's insulin because they could become busy with caring for a resident that had fallen or displayed behaviors related to dementia and document later in the shift their administration of a resident's insulin. The DON stated if RN A and LVN B should have requested assistance from other staff to respond to situations that may have distracted them from documenting immediately the administration of Resident #1's insulin. The DON stated the risk of not documenting the timely administration of a resident's insulin was it would indicate in a resident's medical record the inaccurate administration of medications. Review of facility policy titled, Policy/Procedure-Nursing Clinical Section: Medication Administration revised 05/2007 reflected . Policy: It is the policy of this facility that medications shall be administer as prescribed [NAME] the attending physician. Procedures .7. Medications may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. NOTE: Before and/or after meal orders must be administered as orders .13. The nurse must enter an explanatory note on the reverse side of the Medication Administration Record when drugs are withheld, refused, or given other than at scheduled times . 455904 Page 3 of 5 455904 08/21/2023 Rowlett Health and Rehabilitation Center 9300 Lakeview Pkwy Rowlett, TX 75088

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interview, and record review, the facility failed to maintain an infection prevention and control program that must include, at a minimum, written standards, policies, and procedures for the program which included standard and transmission-based precautions to be followed to prevent spread of infections for one (LVN C) of seven staff reviewed for infection control. Residents Affected - Few LVN C failed to perform hand hygiene between glove changes as he checked blood sugars and provided insulin for Resident #1. This failure could affect residents by placing them at risk for the spread of infection. Findings included: An observation on 08/18/23 at 11:22 AM of LVN C performing a blood sugar check and insulin medication administration for Resident #1 revealed LVN C washed his hands with soap and water and donned gloves after he entered the resident's room. LVN C used an alcohol pad to cleanse the finger of Resident #1 and allowed it to dry. LVN C using a single use needle pricked the finger to Resident #1's right hand and applied a drop of blood to the glucometer test strip and noted a glucometer blood sugar reading of 111 mg/dL. LVN C disposed of lancelet, test strip, and gloves. Without performing hand hygiene, LVN C donned new gloves and disinfected the glucometer with disinfectant wipes and allowed it to dry before returning it to the medication cart. LVN C disposed of his gloves and the disinfectant wipes. Without performing hand hygiene LVN C donned new gloves and removed Resident #1's Insulin Flexpen from the medication cart, verified the physician's medication order and prepared Resident #1's insulin for administration. LVN C took the resident's Insulin Flexpen into Resident #1's room, Resident #1 exposed her abdomen, and with an alcohol pad LVN C cleansed the skin to Resident #1's left lower abdomen and allowed to air dry. LVN C administered the insulin medication to Resident #1's left lower abdomen quadrant. LVN C disposed of the Insulin Flexpen needle, disinfected the resident's Insulin Flexpen with an alcohol pad, removed his gloves and sanitized his hands with ABHR. In an interview on 08/18/23 at 11:34 AM LVN C stated he should perform hand hygiene by either washing his hands with soap and water and or by using ABHR before and after care and when changing his gloves. LVN C stated he performed hand hygiene initially when he entered Resident #1's room but not when changing gloves during the resident's care. LVN C stated it was important to perform hand hygiene when changing gloves to reduce the risk infection to a resident. In an interview on 08/21/23 at 12:00 PM the DON stated staff should perform hand hygiene at the beginning of any task by hand washing or the use of ABHR. The DON stated hand hygiene should also be performed by staff during a task before putting on new gloves, when gloves and or hands were visibly soiled, and when staff were in contact with bodily fluids like blood. The DON stated LVN C should have performed hand hygiene each time he changed his gloves to prevent the risk of infection to the resident. Review of facility policy titled; Hand Hygiene revised 10/2022 reflected It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Purpose: Hand hygiene is one of the most effective measures to prevent the spread of infection .Procedure .2. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents; c. Before preparing or handling 455904 Page 4 of 5 455904 08/21/2023 Rowlett Health and Rehabilitation Center 9300 Lakeview Pkwy Rowlett, TX 75088

F 0880 medications .m. After removing gloves .r. After removing and disposing of personal protective equipment Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455904 Page 5 of 5