Health inspection·August 28, 2023

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 11 residents (Resident #1) reviewed for care plans. Residents Affected - Few The facility failed to ensure Resident #1's care plan included supervision and fall prevention interventions to prevent Resident #1 from falling from her Geri-chair (chairs useful for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair) and sustaining fractures to her hip and pelvis on 7/20/23. An Immediate Jeopardy (IJ) situation was identified on 08/09/23 at 11:40 am. The IJ template was provided to the facility on [DATE] at 11:40 a.m. While the IJ was removed on 08/10/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents, injuries, and death due to lack of supervision and fall preventions. The findings included: Record review of a face sheet dated 07/31/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included Alzheimer's disease (problems with memory, thinking and behavior), repeated falls, and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of an MDS assessment dated [DATE] indicated Resident #1 was sometimes able to understand others and make herself understood, and she had a BIMS of 6 (severe cognitive impairment). She utilized a wheelchair for mobility. She had a history of falls prior to admission. Record review of a care plan dated 06/01/23, indicated Resident #1 had a Geri-chair for comfort. Interventions included honor family wishes. The care plan did not include interventions for safety, accident prevention, or supervision. Record review of a care plan dated 05/16/23 (revised 07/20/23) indicated Resident #1 was at risk for falls. Interventions included anticipate the resident's needs, encourage use of appropriate footwear (SPECIFY even floors free of spills and/or clutter, adequate, glare-free light; a working and reachable call light; bed in low position at night; enabling devices to sides of bed; handrails on walls; personal items within reach), and Resident call light to be placed within reach and encourage the Page 1 of 19 455952 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0656 Level of Harm - Immediate jeopardy to resident health or safety resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The care plan did not address interventions specific to Resident #1's Geri-chair. Record review of a care pan dated 07/21/23 indicated Resident #1 had an actual fall with serious injury and was sent to the ER on [DATE]. Intervention included continue interventions on at risk plan. The care plan did not address Resident #1's level of supervision or fall from the Geri-chair to prevent further falls. Residents Affected - Few Record review of a fall assessment dated [DATE] completed by LVN C indicated a score of 21 (high risk). Record review of an incident report dated 05/26/23, completed by LVN B, indicated Resident #1 fell from her Geri-chair and was on the floor. Family had just left her side. There were no observed injuries. ROM performed and resident was able to move all four limbs. There was no pain noted. Record review of an incident report dated 06/05/23, completed by the DON, indicated Resident #1 was in her Geri-chair. Resident #1 was trying to get up and put her leg between the side of the chair and had a skin tear. Resident #1 was kicking and would not let the DON touch her leg. No additional injuries were noted. Record review of progress note dated 06/12/23 at 3:18 p.m., completed by the Administrator indicated the facility spoke with Resident #1's family regarding the requested Geri-chair. Resident #1's family requested the Geri-chair to replace the high back wheelchair. The family was advised the wheelchair was safest due to Resident #1 putting her legs down the side of the Geri-chair and was frequently found with her legs in an awkward position. Staff frequently put pillows and other positioning devices to cushion the chair and were concerned for her safety. Family stated they still wanted the Geri-chair and understood the risks. The Administrator explained and reiterated the facility would honor Resident #1's and family rights but explained again that the risks could be falls, falls with major injuries, potential for skin tears or entrapment on the side of the geri chair should her leg get stuck. Resident #1's family again stated understanding and wanted to move forward with the Geri-chair. Hospice was notified of the conversation and Geri-chair would be used for Resident #1. Record review of late entry progress note dated 07/20/23 at 3:26 p.m. for effective date of 07/17/23 at 3:24 p.m., completed by the Administrator indicated the facility contacted hospice and asked for assistance for Resident #1 with her Geri-chair. Resident #1 continued to put her legs on the side of the chair and the facility was worried about safety/injury to resident should she have a fall. Hospice indicated they previously ordered a pad for the chair for additional safety. Record review of an incident report dated 07/20/23, completed by LVN B, indicated CNA D noticed Resident #1 was sitting on the floor. Resident #1 was scooting on her buttocks and displayed no signs of pain. Head to toe assessment and range of motion was performed with no signs of pain or discomfort. Resident #1 was placed in bed and she had delayed complaint of pain. Hospice was notified and ordered x-ray of left leg. Resident #1's pain level was a 10 and she was alert. CNA D had exited the room prior to Resident #1's fall to pass lunch trays. Record review of a progress note dated 07/20/23 at 12:21 p.m., completed by LVN B, indicated Resident #1 was on the floor sitting on her buttocks. Performed ROM and no complaint of pain to bilateral legs. 455952 Page 2 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of progress note dated 07/20/23 at 12:36 p.m., completed by LVN B indicated head to toe assessment performed and ROM with no complaint of pain or discomfort. Resident was scooting her buttocks on the floor to the bed by the door (roommate's bed) with no pain and trying to get off the floor. CNA D assisted her off the floor and onto her bed. Record review of progress note dated 07/20/23 at 12:52 p.m., completed by LVN B, indicated Resident #1 was sitting on the floor and scooting on her bottom to the bed next to her. ROM was done and Resident #1 was able to move both legs with no pain or discomfort. There was no open or raised area to her head. Record review of progress note dated 07/20/23 at 12:52 p.m., completed by LVN B, indicated hospice returned call to facility and ordered x-ray to left leg, hip and upper and lower leg. Record review of progress note dated 07/20/23 at 1:46 p.m., completed by LVN B, indicated Resident #1's family arrived and Resident #1 was in pain. Family did not want to wait for STAT (x-ray) as it was taking too long and wanted Resident #1 sent out 911 (emergency). Record review of progress note dated 07/20/23 at 3:26 p.m., completed by the Administrator, indicated she spoke with family in office after resident had a fall. Family was concerned resident had fall out of Geri-chair and explained they were going to meet her at the ER for her evaluation and possible treatment. Family wanted the tray to be placed over the Geri-chair at all times to prevent her from getting up. The administrator explained to family that the facility was not able to impede movement of a resident as the facility did not want to restrain residents and it caused even more risk for injury. Resident #1's family member stated she got approval for the tray. The administrator asked the family member who she got approval from and she said the name of the administrator. The administrator informed the family member that was never a conversation that was had and asked if she was thinking of someone else. The family member said she was not sure but she wanted the tray. The administrator began to try and continue conversation and the family member stated she needed to go to meet Resident #1 at the hospital. Record review of hospital records dated 07/20/23 indicated Resident #1 sustained an acute comminuted intertrochanteric fracture of the left femur with impaction, foreshortening, and varus angulation (hip fracture) and a subacute mildly displaced fracture of the right pubic body (part of the pelvis) as well as a subacute nondisplaced right inferior ramus (part of the pubis) . and subacute nondisplaced longitudinal fracture of the right hemisacrum (sacral vertebrae). During an interview on 07/27/23 at 11:37 a.m., LVN B said on 7/20/23 CNA D pushed Resident #1 (in a wheelchair) to her room after she (Resident #1) ate lunch and transferred to her Geri-chair. She said she was called to the room and found Resident #1 on the floor beside her Geri-chair. She was sitting on her buttocks. LVN B said Resident #1 was scooting on her buttocks toward her roommate's bed. She said she assessed Resident #1. Resident #1 was moving all her limbs and had no signs of pain. She said she told CNA D to put her back in the bed. She said CNA D and CNA E picked Resident #1 up and put her in bed. She said she walked back to the nurse station and called hospice and the family. She said she had not given any medications for pain when she called hospice or the family. Hospice ordered an x-ray. She said she heard hollering and was getting the pain medication ready when the family arrived. She said she arrived in the room with the medication but the family did not want the morphine given. She said she explained the effectiveness of morphine and the family changed their mind. She said Resident #1 did have fall mat for use by the bed but could not recall where the fall mat was after Resident #1 fell from the Geri-chair. Resident #1's family did not want to wait for the 455952 Page 3 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0656 Level of Harm - Immediate jeopardy to resident health or safety x-ray to be done in the facility and wanted her sent out to the hospital. She said she notified hospice and hospice indicated they were already on the way to evaluate her. Hospice agreed to send her to the hospital. She said the family blamed the facility for Resident #1 falling and getting out of the Geri-chair. She said Resident #1 was usually at the nurse's station or in the common area across from the nurse station when she was in the Geri-chair. She said she did not know if Resident #1 was supposed to be left alone in her room in the geri-chair. Residents Affected - Few During an interview on 07/27/23 at 12:46 p.m., CNA D said she took Resident #1 to her room after lunch in the dining room. She said she transferred her to her Geri-chair. She said she put pillows and a blanket on the chair and set her in front of the TV. She said she left the room to continue delivering lunch trays. CNA D said she was going to put Resident #1 in bed after she finished delivering lunch trays. She walked by the room once and Resident #1 was in her chair. She said she went into another resident's room and heard a loud noise. She said she came out of the room and saw Resident #1 on the floor. CNA D said she called for LVN B and reported Resident #1 fell from her Geri-chair to the floor. Resident #1 was laying on the floor then she sat up and started scooting on the floor on her buttocks. She was not crying and had no pain. LVN B asked her to lift her foot to see if she could stretch it out and move it. She did not cry or complain. LVN B left the room. She said (CNA D) used a gait belt to lift her off the floor and put her in bed. Resident #1 did not cry in pain until she put her in bed. She said she went to the nurse station and told LVN B. LVN B said she would give her some pain medication. She said Resident #1's family arrived around the same time she told the nurse of Resident #1's pain. She said Resident #1 was usually a 1-person assist with care or transfers unless she was aggressive. During an interview on 07/31/23 at 9:37 a.m., the Administrator said fall interventions were not in Resident #1's care plan. She said the interventions were being documented in the incident reports but not placed into the care plan. She said it was probably due to the change in MDS staffing. She said the DON would continue to monitor and follow up- to ensure all residents' care plans were completed as required. During an interview on 07/31/23 at 11:21 a.m., MDS LVN I said she took over the MDS position in May 2023. She said Resident #1's care plans were not completed and did not include supervision in the Geri-chair. She said it was just missed. She said normally, the MDS was completed and then the care plans were completed. She said the care plans populate the care record. During an interview on 07/31/23 at 11:55 a.m., the Administrator said Resident #1's baseline status was 1-person transfer. She said it was the facility's expectation the care plan was completed after the MDS as required for each resident. She said Resident #1's care plan was missed and not completed during staff transition in May 2023. She said residents were at risk of not receiving care as required if their care plans were not completed. During an interview on 07/31/23 at 1:38 p.m., the DON said Resident #1 was admitted to the facility from home due to falls. She said Resident #1's family wanted the Geri-chair. She said hospice provided a high back wheelchair and Resident #1 had a fall. She said the family insisted on the Geri-chair. She said the chair was provided by hospice services. She said the family was educated on the risks. She said Resident #1 had extra care and supervision when she was in the chair. She said Resident #1 was at the nurse station or in the sensory room across from the nurse station. She said sometimes the aides would put her in room without supervision. She said sometimes Resident #1 was in her bed when she was in her room. She said a family member would frequently be with Resident #1 per family preference. She said she believed a fall mat was in place on the floor next to the bed when Resident 455952 Page 4 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few #1 was in her bed. She said she was not sure why Resident #1's care plan was not specific to fall prevention related to the Geri-chair. She said fall mats were usually added to fall prevention care plans. She said it was the facility's expectation the residents' care plans were completed as required. She said residents were at risk of not receiving care as required if their care plans were not completed. During an interview on 08/02/23 at 4:30 p.m., the Administrator said Resident #1's family member and family were advised of the dangers of Resident #1 using a Geri-chair, including falls. She said the family was advised the Geri-chair was not the safest for Resident #1 but they wanted to continue the use of the Geri-chair. She said the family wanted the tray on the Geri-chair utilized to keep Resident #1 in the chair. She said the facility was restraint-free and the tray was removed from the chair. She said the facility did not have enhanced supervision for Resident #1 when she was in the Geri-chair. She said she was not aware Resident #1's care plans were not completed. Record review of the facility's Care Plan policy dated 2001 (revised March 2022) indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Administrator and DON were notified of the Immediate Jeopardy on 08/09/23 at 11:40 a.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/10/23 at 7:04 a.m. and reflected the following: Resident # 1 was sent to the hospital on 7/20/2023 and did not return. Resident #1 admitted to a new skilled nursing facility and will not be returning to [the facility]. The Geri-chair used by resident #1 was picked up after resident discharged and will not be returning to [the facility]. There are no other Geri-Chairs at [the facility]. 8/9/2023: All residents determined at risk for fall and/or accidents/hazards by therapy related to mobility device, including wheelchairs, rollators, walkers, canes, etc. had plan of care reviewed and/or updated by nursing administration as needed. 100% of residents will be reviewed by nursing administration to determine they have up to date fall risk assessments and appropriate interventions in place in the care plan. Will be completed by 9 pm on 8/9/2023. 8/9/23: All staff in the facility will be in-serviced on fall risks related to mobility devices including wheelchairs, rollators, walkers, canes, etc by 9 pm on 8/9/23. Any staff not in the facility will not be allowed to work until they receive the training and post-test. This training will be included in the new hire orientation process to be completed by nursing administration for new hires and temporary staff.? This training will be conducted by facility Administrator, Administrative Nursing Team, Regional Compliance Nurse, and Regional Director of Rehabilitation for a local therapy provider.? 8/9/23: Ad-Hoc QAPI will be completed on 8/9/23 by 9 pm with QAPI Committee including Medical Director related to alleged failure to prevent residents from receiving appropriate care and interventions to prevent residents from falling and sustaining serious injury or harm and the alleged failure to provide adequate supervision and assistance to prevent accidents. QAPI will also include the alleged failure to develop and implement a comprehensive person-centered care plan for each resident to 455952 Page 5 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment.? A post-test will be given to all staff by DON or designee to show competency at the time of inservicing.? They must pass with 100%. Staff will include nursing, dietary, maintenance, housekeeping, & therapy. New admission chart checks of residents determined to be a high risk for falls utilizing a mobility device including wheelchairs, rollators, walkers, canes, etc. that could potentially pose accidents/hazards will be referred to therapy by DON or IDT members for immediate screening of device use, knowledge, and understanding. If device is deemed to be inappropriate upon therapy screening, therapy evaluation will be made and immediate action taken by therapy to determine an appropriate device for use.? If a family and/or resident still chooses to use the device including wheelchairs, rollators, walkers, canes, etc., if the device is deemed unsafe for the resident, the facility will work with family on a safe and appropriate discharge plan for the resident.? On 08/10/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 08/10/23 at 2:30 p.m., the Administrator said all residents had been reviewed by therapy and nursing administration to determine appropriateness of mobility devices used and fall risk. Care plans of residents evaluated to be at risk of falls had been reviewed and updated by nursing administration. She said nursing staff had completed in-service training on fall risks related to mobility devices and required to pass a post test at the completion of the in-service. During an interview on 08/10/23 at 2:40 p.m., the DON said new admission charts of residents determined to be at high risk of falls or high risk of falls using mobility devices would be referred to therapy for immediate screening of device use, knowledge, and understanding. She said QAPI meeting was held 08/09/23 and plans were approved for therapy evaluations, care plan updates, and in-service trainings. Monitoring system was determined and started. She said during morning meetings and QAPI all new admissions would be reviewed to ensure resident assessments and level of supervision were adequate to meet their needs. During an interview on 08/10/23 at 3:00 p.m., the ADON said she was assisting the DON in new admission chart checks. She said any resident determined to be at high risk for falls or poor safety with mobility device would be immediately referred to therapy for safety evaluation. During an interview on 08/10/23 at 3:10 p.m., the DOR said all residents had been reviewed for safety and fall risk and safety with mobility devices. Evaluations were documented and given to nursing administration. During interviews on 08/10/23 from 3:20 p.m. to 4:30 p.m. with 3 LVNs and 3 CNAs who normally worked the 6 a.m. to 6 p.m. shift and 3 LVNs and 3 CNAs who normally worked the 6 p.m. to 6 a.m. shift indicated they were able to correctly state fall risks related to mobility devices, changes in mobility or safety, and notification of nursing administration and physical therapy if they noted changes in a resident's condition, ADLs, or mobility status. Record review of facility in-services dated 08/09/23 and 08/10/23 indicated staff were trained regarding fall risks related to mobility devices including wheelchairs, rollators, walkers, and canes. 455952 Page 6 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of post tests dated 08/09/23 and 08/10/23 indicated staff were tested on fall risks related to mobility devices including wheelchairs, rollators, walkers, and canes and scored 100%. Record review of facility therapy mobility device screen indicated all residents had been reviewed/evaluated by therapy for fall risk and safety with mobility devices and mobility. On 08/10/23 at 4:55 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. On 08/28/23, the surveyor re-entered the facility. During an interview on 08/28/23 at 10:10 a.m., the Administrator and DON said they implemented a no Geri-chair policy effective 08/01/23. They Administrator and DON said after Resident #1 discharged to another facility, the Geri-chair was picked up and there were no other Geri-chairs in the facility. They said the facility completed an audit of residents and fall risk assessments on 08/09/23 and the IDT did not identify any current residents at risk. During observations on 08/28/23 from 10:54 a.m. to 08/28/23 at 4:30 p.m., 11 residents that used wheelchairs for mobility and were at risk for falls were observed (8 residents in their room and 3 residents in common areas). There were no fall hazards observed in resident rooms, common areas, secure unit, or halls. Fall interventions observed included beds in the lowest position, scoop mattresses, fall mats, and call lights/water within reach. Call lights were answered in less than 3 minutes. Staff were observed checking on residents on enhanced supervision every 15 minutes. There were no Geri-chairs observed in the facility. During interviews on 08/28/23 at 11:00 a.m. to 08/28/23 at 4:00 p.m., 4 nurses and 6 CNAs (that worked all shifts) said they were trained on 08/9/23 and 08/10/23 and were aware of each resident's level of supervision and provided examples of fall interventions. Staff said a resident's level of supervision was on the resident's care plan and [NAME]. Staff said they would notify the DON, ADON or charge nurse if there was a concern or issue related to resident falls, fall interventions, or level of supervision. Staff said they were trained on accident prevention and supervision and use the 24-report to document communication with other staff about any resident issues or concerns. During interviews on 08/28/23 at 11:13 a.m. to 08/28/23 at 3:00 p.m., 6 residents at risk for falls said staff checked on them regularly and they had no concerns. Record review of two new admission and readmission resident assessments indicated fall risk/safety assessments were completed and accurate. Record review of fall risk assessments of 11 residents at risk for falls were complete and included appropriate fall interventions. Record review of care plans of 11 residents at risk for falls included appropriate fall interventions. Record review of the facility's audit of residents and falls risks completed 08/09/23 indicated the IDT did not identify any current residents at risk of having safety issues related to being left 455952 Page 7 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0656 alone in their wheelchair. Level of Harm - Immediate jeopardy to resident health or safety Record review of the facility's Geri-chair policy dated 08/01/23 indicated .the facility will not admit a resident with a geri-chair. Hospice will be notified to not bring a geri-chair for their patients. Therapy will evaluate the most appropriate mobility device for a resident if there is a change of condition including broda chairs or reclining wheelchairs . Residents Affected - Few 455952 Page 8 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate assistance and supervision to prevent accidents for 1 of 11 residents (Resident #1) reviewed for accidents. Residents Affected - Few The facility failed to ensure adequate supervision to prevent falls. On 7/20/23, Resident #1 fell out of her Geri-chair (chairs useful for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair) and sustained a fractured left hip and fractured pelvis that required surgical intervention. An Immediate Jeopardy (IJ) situation was identified on 08/09/23 at 11:40 am. The IJ template was provided to the facility on [DATE] at 11:40 a.m. While the IJ was removed on 08/10/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents, injuries, and death due to lack of supervision and fall interventions. Findings included: Record review of a face sheet dated 07/31/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included Alzheimer's Disease (problems with memory, thinking and behavior), repeated falls, and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Resident #1 was discharged to hospital on [DATE] and not readmitted to the facility. Record review of an MDS assessment dated [DATE] indicated Resident #1 was sometimes able to understand others and make herself understood, and she had a BIMS of 6 (severe cognitive impairment). She required extensive physical assist of one staff for bed mobility and toileting. She utilized a wheelchair for mobility. She had a history of falls prior to admission. Record review of an undated care plan provided by the facility on 07/31/23 indicated Resident #1 was at risk for falls. Interventions included anticipate the resident's needs, encourage use of appropriate footwear (SPECIFY even floors free of spills and/or clutter, adequate, glare-free light; a working and reachable call light; bed in low position at night; enabling devices to sides of bed; handrails on walls; personal items within reach), and Resident call light to be placed within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The care plan did not address interventions specific to Resident #1's Geri-chair. Record review of a care pan dated 07/21/23 indicated Resident #1 had an actual fall with serious injury and was sent to the ER on [DATE]. Intervention included continue interventions on at risk plan. The care plan did not address Resident #1's level of supervision or fall from the Geri-chair to prevent further falls. Record review of a care plan dated 06/01/23, indicated Resident #1 had a Geri-chair for comfort. 455952 Page 9 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0689 Interventions included honor family wishes. The care plan did not include interventions for safety, accident prevention, or supervision. Level of Harm - Immediate jeopardy to resident health or safety Record review of a fall assessment dated [DATE] completed by LVN C indicated a score of 21 (high risk). Residents Affected - Few Record review of an incident report dated 05/26/23, completed by LVN B, indicated Resident #1 fell from her Geri-chair and was on the floor. Family had just left her side. There were no observed injuries. ROM performed and resident was able to move all four limbs. There was no pain noted. Record review of an incident report dated 06/05/23, completed by the DON, indicated Resident #1 was in her Geri-chair. Resident #1 was trying to get up and put her leg between the side of the chair and had a skin tear. Resident #1 was kicking and would not let the DON touch her leg. No additional injuries were noted. Record review of progress note dated 06/12/23 at 3:18 p.m., completed by the Administrator indicated the facility spoke with Resident #1's family regarding the requested Geri-chair. Resident #1's family requested the Geri-chair to replace the high back wheelchair. The family was advised the wheelchair was safest due to Resident #1 putting her legs down the side of the Geri-chair and was frequently found with her legs in an awkward position. Staff frequently put pillows and other positioning devices to cushion the chair and were concerned for her safety. Family stated they still wanted the Geri-chair and understood the risks. The Administrator explained and reiterated the facility would honor Resident #1's and family rights but explained again that the risks could be falls, falls with major injuries, potential for skin tears or entrapment on the side of the geri chair should her leg get stuck. Resident #1's family again stated understanding and wanted to move forward with the Geri-chair. Hospice was notified of the conversation and Geri-chair would be used for Resident #1. Record review of late entry progress note dated 07/20/23 at 3:26 p.m. for effective date of 07/17/23 at 3:24 p.m., completed by the Administrator indicated the facility contacted hospice and asked for assistance for Resident #1 with her Geri-chair. Resident #1 continued to put her legs on the side of the chair and the facility was worried about safety/injury to resident should she have a fall. Hospice indicated they previously ordered a pad for the chair for additional safety. Record review of an incident report dated 07/20/23, completed by LVN B, indicated CNA D noticed Resident #1 was sitting on the floor. Resident #1 was scooting on her buttocks and displayed no signs of pain. Head to toe assessment and range of motion was performed with no signs of pain or discomfort. Resident #1 was placed in bed and she had delayed complaint of pain. Hospice was notified and ordered x-ray of left leg. Resident #1's pain level was a 10 and she was alert. CNA D had exited the room prior to Resident #1's fall to pass lunch trays. Record review of a progress note dated 07/20/23 at 12:21 p.m., completed by LVN B, indicated Resident #1 was on the floor sitting on her buttocks. Performed ROM and no complaint of pain to bilateral legs. Record review of progress note dated 07/20/23 at 12:36 p.m., completed by LVN B indicated head to toe assessment performed and ROM with no complaint of pain or discomfort. Resident was scooting her buttocks on the floor to the bed by the door (roommate's bed) with no pain and trying to get off the floor. CNA D assisted her off the floor and onto her bed. 455952 Page 10 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Record review of progress note dated 07/20/23 at 12:52 p.m., completed by LVN B, indicated Resident #1 was sitting on the floor and scooting on her bottom to the bed next to her. ROM was done and Resident #1 was able to move both legs with no pain or discomfort. There was no open or raised area to her head. Record review of progress note dated 07/20/23 at 12:52 p.m., completed by LVN B, indicated hospice returned call to facility and ordered x-ray to left leg, hip and upper and lower leg. Residents Affected - Few Record review of progress note dated 07/20/23 at 1:46 p.m., completed by LVN B, indicated Resident #1's family arrived and Resident #1 was in pain. Family did not want to wait for STAT (x-ray) as it was taking too long and wanted Resident #1 sent out 911 (emergency). Record review of progress note dated 07/20/23 at 1:47 p.m., completed by LVN B, indicated Resident #1's family members asked for pain medication for delayed pain. Record review of progress note dated 07/20/23 at 3:26 p.m., completed by the Administrator, indicated she spoke with family in office after resident had a fall. Family was concerned resident had fall out of Geri-chair and explained they were going to meet her at the ER for her evaluation and possible treatment. Family wanted the tray to be placed over the Geri-chair at all times to prevent her from getting up. The administrator explained to family that the facility was not able to impede movement of a resident as the facility did not want to restrain residents and it caused even more risk for injury. Resident #1's family member stated she got approval for the tray. The administrator asked the family member who she got approval from and she said the name of the administrator. The administrator informed the family member that was never a conversation that was had and asked if she was thinking of someone else. The family member said she was not sure but she wanted the tray. The administrator began to try and continue conversation and the family member stated she needed to go to meet Resident #1 at the hospital. Record review of Resident #1's physician orders dated 05/17/23 indicated: -morphine sulfate oral solution 20 mg/5 ml .25 ml by mouth every 2 hours as needed for pain/SOB. Record review of Resident #1's physician orders dated 05/20/23 indicated hydrocodone-acetaminophen oral tab 5-325 mg 1 tab by mouth every 6 hours as needed for pain. Record review of Resident #1's MAR dated 07/20/23 indicated LVN B administered Resident #1 morphine sulfate oral solution 20/mg/5 ml .25 at 1:11 p.m. Record review of hospital records dated 07/20/23 indicated Resident #1 had a fall with hip pain and sustained an acute comminuted intertrochanteric fracture of the left femur with impaction, foreshortening, and varus angulation (hip fracture) and a subacute mildly displaced fracture of the right pubic body (part of the pelvis) as well as a subacute nondisplaced right inferior ramus (part of the pubis) . and subacute nondisplaced longitudinal fracture of the right hemisacrum (sacral vertebrae). Record review of the facility investigation dated 07/26/23 indicated On 07/20/23 Resident #1, was noted to have an unwitnessed fall in her room. LVN B evaluated and no apparent distress or injury upon immediate assessment. Resident #1 began complaining of pain while in bed shortly thereafter the fall. Facility immediately notified MD and Hospice and medicated the resident for pain. Hospice gave orders for STAT Xray to hip due to complaint of pain. Resident family arrived and opted to go ahead and send Resident #1 to (hospital) for further eval and treatment instead of waiting for the x-ray. 455952 Page 11 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0689 Facility was notified on 07/20/23 that Resident #1 was admitted with an acute left hip fracture. Level of Harm - Immediate jeopardy to resident health or safety Upon investigation. Resident #1 was ambulating without assist in her room when she had the fall. Residents Affected - Few Resident has a history of frequent falls. Resident has Alzheimer's disease and is on hospice services. Resident #1 is extensive assist with poor safety awareness. Resident #1 is not interviewable and a poor historian. Resident does have a roommate, however roommate is not interviewable. Staff interviews were initiated and staff report that Resident #1 had just been brought back to her room after lunch as she eats in the main dining room. After they brought her back to her room, they began passing trays to the rest of the residents on the hall and it was this at this time, she had her fall. Resident #1 will be evaluated and seen by therapy upon return back from the hospital and will be readmitted on hospice services. Resident family member, MD and Ombudsman notified of the incident. In service initiated with staff on fall prevention. Inservice initiated on Abuse and Neglect. Resident had L (left) hip surgery on Friday 07/21/23 and is stable at this time. In conclusion, after a thorough investigation the facility determines the injury of unknown origin to be unfounded. The L (left) hip fracture was a direct result of her fall that occurred on 07/20/23. The resident (Resident #1) will be monitored closely once returned to the facility. The facility will continue to monitor the well-being of the residents. During an interview on 07/27/23 at 11:37 a.m., LVN B said on 7/20/23 CNA D pushed Resident #1 (in a wheelchair) to her room after she (Resident #1) ate lunch and transferred to her Geri-chair. She said she was called to the room and found Resident #1 on the floor beside her Geri-chair. LVN B said Resident #1 was sitting on her buttocks. LVN B said Resident #1 was scooting on her buttocks toward her roommate's bed. She said she assessed Resident #1. Resident #1 was moving all her limbs and had no signs of pain. She said she told CNA D to put her back in the bed. She said she assumed CNA D and CNA E picked Resident #1 up and put her in bed. She said she walked back to the nurse station and called hospice and the family. She said she had not given any medications for pain when she called hospice or the family. Hospice ordered an x-ray. She said she heard hollering and was getting the pain medication ready when the family arrived. She said she arrived in the room with the medication but the family did not want the morphine given. She said she explained the effectiveness of morphine and the family changed their mind. She said Resident #1 did have fall mat for use by the bed but could not recall where the fall mat was after Resident #1 fell from the Geri-chair. Resident #1's family did not want to wait for the x-ray to be done in the facility and wanted her sent out to the hospital. She said she notified hospice and hospice indicated they were already on the way to evaluate her. Hospice agreed to send her to the hospital. She said the family blamed the facility for Resident #1 falling and getting out of the Geri-chair. She said Resident #1 was usually at the nurse station or in the common area across from the nurse station when she was in the Geri-chair. She said she did not know if Resident #1 was supposed to be left alone in her room in the geri-chair. During an interview on 07/27/23 at 11:58 a.m., a family member said the first call from the facility on 7/20/23 was at 12:23 p.m. and she was informed of Resident #1's fall. She said she arrived at 455952 Page 12 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the facility about 1 hour later and Resident #1 was screaming. She said there was no staff in the room. She said Resident #1 was in her bed. She said the fall mat was rolled up and against the wall. She said Resident #1 was left alone in her room and had fallen from the Geri-chair. During an interview on 07/27/23 at 12:36 a.m., CNA E said CNA D took Resident #1 to her room after lunch in the dining room. She said she was delivering lunch trays on the hall. She said Resident #1's Geri-chair was in the middle of the room in front of the TV. Resident #1 was sitting on her buttocks and she was scooting on the floor. She said LVN B was in the room with CNA D. She said she left the room to continue delivering lunch trays on the hall. During an interview on 07/27/23 at 12:46 p.m., CNA D said she took Resident #1 to her room after lunch in the dining room. She said she transferred her to her Geri-chair. She said she put pillows and a blanket on the chair and set her in front of the TV. She said she left the room to continue delivering lunch trays. CNA D said she was going to put Resident #1 in bed after she finished delivering lunch trays. She walked by the room once and Resident #1 was in her chair. She said she went into another resident's room and heard a loud noise. She said she came out of the room and saw Resident #1 on the floor. CNA D said she called for LVN B and reported Resident #1 fell from her Geri-chair to the floor. Resident #1 was laying on the floor then she sat up and started scooting on the floor on her buttocks. She was not crying and had no pain. LVN B asked me to lift her foot to see if she could stretch it out and move it. She did not cry or complain. LVN B left the room. CNA D said she used a gait belt to lift Resident #1 off the floor and put her in bed by herself. Resident #1 did not cry in pain until she put her in bed. She went to the nurse station and told LVN B of Resident #1's pain. LVN B said she would give her some pain medication. She said Resident #1's family arrived around the same time she told LVN B of Resident #1's pain. During an interview on 07/27/23 at 4:30 p.m., the Administrator said Resident #1's family members were advised of the dangers of Resident #1 using a Geri-chair, including falls. She said the family was advised the Geri-chair was not the safest for Resident #1 but they wanted to continue the use of the Geri-chair. She said the family wanted the tray on the Geri-chair utilized to keep Resident #1 in the chair. She said the facility was restraint-free and the tray was removed from the chair. She said the facility did not have enhanced supervision for Resident #1 when she was in the Geri-chair. During an interview on 07/31/23 at 1:38 p.m., the DON said she was out of the facility and did not have her computer to access information. She said Resident #1 was admitted to the facility from home due to falls. She said Resident #1's family wanted the Geri-chair. She said hospice provided a high back wheelchair and Resident #1 had a fall. She said the family insisted on the Geri-chair. She said the chair was provided by hospice services. She said the family was educated on the risks. She said Resident #1 had extra care and supervision when she was in the chair. She said Resident #1 was at the nurse station or in the sensory room across from the nurse station. She said sometimes the aides would put her in room without supervision. She said sometimes Resident #1 was in her bed when she was in her room. She said a family member would frequently be with Resident #1 per family preference. Record review of the facility's Safety and Supervision policy dated 2001 (revised July 2017) indicated: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Individualized, Resident-Centered Approach to Safety-1. Our individualized resident-centered approach to safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observation to identify any specific accident and hazards 455952 Page 13 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards . 5. Monitoring the effectiveness of interventions . Systems Approach to Safety-1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual risk factors, and then adjust interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of residents supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among resident and over time for the same resident. During an interview via email on 08/07/23 at 10:18 a.m., the Administrator indicated the facility did not have a policy for the use Geri-chairs. The Administrator and DON were notified of the Immediate Jeopardy on 08/09/23 at 11:40 a.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/10/23 at 7:04 a.m. and reflected the following: Resident # 1 was sent to the hospital on 7/20/2023 and did not return. Resident #1 admitted to a new skilled nursing facility and will not be returning to [the facility]. The Geri-chair used by resident #1 was picked up after resident discharged and will not be returning to [the facility]. There are no other Geri-Chairs at [the facility]. 8/9/2023: All residents determined at risk for fall and/or accidents/hazards by therapy related to mobility device, including wheelchairs, rollators, walkers, canes, etc. had plan of care reviewed and/or updated by nursing administration as needed. 100% of residents will be reviewed by nursing administration to determine they have up to date fall risk assessments and appropriate interventions in place in the care plan. Will be completed by 9 pm on 8/9/2023. 8/9/23: All staff in the facility will be in-serviced on fall risks related to mobility devices including wheelchairs, rollators, walkers, canes, etc by 9 pm on 8/9/23. Any staff not in the facility will not be allowed to work until they receive the training and post-test. This training will be included in the new hire orientation process to be completed by nursing administration for new hires and temporary staff.? This training will be conducted by facility Administrator, Administrative Nursing Team, Regional Compliance Nurse, and Regional Director of Rehabilitation for a local therapy provider.? 8/9/23: Ad-Hoc QAPI will be completed on 8/9/23 by 9 pm with QAPI Committee including Medical Director related to alleged failure to prevent residents from receiving appropriate care and interventions to prevent residents from falling and sustaining serious injury or harm and the alleged failure to provide adequate supervision and assistance to prevent accidents. QAPI will also include the alleged failure to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment.? A post-test will be given to all staff by DON or designee to show competency at the time of 455952 Page 14 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few inservicing.? They must pass with 100%. Staff will include nursing, dietary, maintenance, housekeeping, & therapy. New admission chart checks of residents determined to be a high risk for falls utilizing a mobility device including wheelchairs, rollators, walkers, canes, etc. that could potentially pose accidents/hazards will be referred to therapy by DON or IDT members for immediate screening of device use, knowledge, and understanding. If device is deemed to be inappropriate upon therapy screening, therapy evaluation will be made and immediate action taken by therapy to determine an appropriate device for use.? If a family and/or resident still chooses to use the device including wheelchairs, rollators, walkers, canes, etc., if the device is deemed unsafe for the resident, the facility will work with family on a safe and appropriate discharge plan for the resident.? On 08/10/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 08/10/23 at 2:30 p.m., the Administrator said all residents had been reviewed by therapy and nursing administration to determine appropriateness of mobility devices used and fall risk. Care plans of residents evaluated to be at risk of falls had been reviewed and updated by nursing administration. She said nursing staff had completed in-service training on fall risks related to mobility devices and required to pass a post test at the completion of the in-service. During an interview on 08/10/23 at 2:40 p.m., the DON said new admission charts of residents determined to be at high risk of falls or high risk of falls using mobility devices would be referred to therapy for immediate screening of device use, knowledge, and understanding. She said QAPI meeting was held 08/09/23 and plans were approved for therapy evaluations, care plan updates, and in-service trainings. Monitoring system was determined and started. She said during morning meetings and QAPI all new admissions would be reviewed to ensure resident assessments and level of supervision were adequate to meet their needs. During an interview on 08/10/23 at 3:00 p.m., the ADON said she was assisting the DON in new admission chart checks. She said any resident determined to be at high risk for falls or poor safety with mobility device would be immediately referred to therapy for safety evaluation. During an interview on 08/10/23 at 3:10 p.m., the DOR said all residents had been reviewed for safety and fall risk and safety with mobility devices. Evaluations were documented and given to nursing administration. During interviews on 08/10/23 from 3:20 p.m. to 4:30 p.m. with 3 LVNs and 3 CNAs who normally worked the 6 a.m. to 6 p.m. shift and 3 LVNs and 3 CNAs who normally worked the 6 p.m. to 6 a.m. shift indicated they were able to correctly state fall risks related to mobility devices, changes in mobility or safety, and notification of nursing administration and physical therapy if they noted changes in a resident's condition, ADLs, or mobility status. Record review of facility therapy mobility device screen indicated all residents had been reviewed/evaluated by therapy for fall risk and safety with mobility devices and mobility. Record review of facility in-services dated 08/09/23 and 08/10/23 indicated staff were trained regarding fall risks related to mobility devices including wheelchairs, rollators, walkers, and canes. 455952 Page 15 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of post tests dated 08/09/23 and 08/10/23 indicated staff were tested on fall risks related to mobility devices including wheelchairs, rollators, walkers, and canes and scored 100%. On 08/10/23 at 4:55 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. On 08/28/23, the surveyor re-entered the facility. During an interview on 08/28/23 at 10:10 a.m., the Administrator and DON said they implemented a no Geri-chair policy effective 08/01/23. They Administrator and DON said after Resident #1 discharged to another facility, the Geri-chair was picked up and there were no other Geri-chairs in the facility. They said the facility completed an audit of residents and fall risk assessments on 08/09/23 and the IDT did not identify any current residents at risk. During observations on 08/28/23 from 10:54 a.m. to 08/28/23 at 4:30 p.m., 11 residents that used wheelchairs for mobility and were at risk for falls were observed (8 residents in their room and 3 residents in common areas). There were no fall hazards observed in resident rooms, common areas, secure unit, or halls. Fall interventions observed included beds in the lowest position, scoop mattresses, fall mats, and call lights/water within reach. Call lights were answered in less than 3 minutes. Staff were observed checking on residents on enhanced supervision every 15 minutes. There were no Geri-chairs observed in the facility. During interviews on 08/28/23 at 11:00 a.m. to 08/28/23 at 4:00 p.m., 4 nurses and 6 CNAs (that worked all shifts) said they were trained on 08/9/23 and 08/10/23 and were aware of each resident's level of supervision and provided examples of fall interventions. Staff said a resident's level of supervision was on the resident's care plan and [NAME]. Staff said they would notify the DON, ADON or charge nurse if there was a concern or issue related to resident falls, fall interventions, or level of supervision. Staff said they were trained on accident prevention and supervision and use the 24-report to document communication with other staff about any resident issues or concerns. During interviews on 08/28/23 at 11:13 a.m. to 08/28/23 at 3:00 p.m., 6 residents at risk for falls said staff checked on them regularly and they had no concerns. Record review of two new admission and readmission resident assessments indicated fall risk/safety assessments were completed and accurate. Record review of fall risk assessments of 11 residents at risk for falls were complete and included appropriate fall interventions. Record review of care plans of 11 residents at risk for falls included appropriate fall interventions. Record review of the facility's audit of residents and falls risks completed 08/09/23 indicated the IDT did not identify any current residents at risk of having safety issues related to being left alone in their wheelchair. Record review of the facility's Geri-chair policy dated 08/01/23 indicated .the facility will not 455952 Page 16 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0689 Level of Harm - Immediate jeopardy to resident health or safety admit a resident with a geri-chair. Hospice will be notified to not bring a geri-chair for their patients. Therapy will evaluate the most appropriate mobility device for a resident if there is a change of condition including broda chairs or reclining wheelchairs . Residents Affected - Few 455952 Page 17 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 11 residents (Resident #1) reviewed for medication administration. The facility failed to ensure LVN B administered Resident #1's medication per policy. LVN B gave Resident #1's family member a hydrocodone tablet (controlled pain medication) to administer to Resident #1 rather than attempting to administer the medication herself. This failure could place residents at risk of not receiving all their prescribed medication as ordered. The findings were: Record review of a face sheet dated 07/31/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included Alzheimer's (problems with memory, thinking and behavior), repeated falls, and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Record review of an MDS assessment dated [DATE] indicated Resident #1 was sometimes able to understand others and make herself understood, she had a BIMS of 6 (severe cognitive impairment). She utilized a wheelchair for mobility. She had a history of falls prior to admission. Record review of an incident report dated 07/20/23, completed by LVN B, indicated CNA D noticed Resident #1 was sitting on the floor. Resident #1 was scooting on her buttocks and displayed no signs of pain. Head to toe assessment and range of motion was performed with no signs of pain or discomfort. Resident #1 was placed in bed and she had delayed complaint of pain. Hospice was notified and ordered x-ray of left leg. Resident #1's pain level was a 10 and she was alert. CNA D had exited the room prior to Resident #1's fall to pass lunch trays. Record review of a progress note dated 07/20/23 at 12:52 p.m., completed by LVN B, indicated hospice returned call to facility and ordered x-ray to left leg, hip and upper and lower leg. Record review of a progress note dated 07/20/23 at 1:46 p.m., completed by LVN B, indicated Resident #1's family arrived and Resident #1 was in pain. Family did not want to wait for STAT (x-ray) as it was taking too long and wanted Resident #1 sent out 911 (emergency). Record review of Resident #1's physician orders dated 05/20/23 indicated hydrocodone-acetaminophen oral tab 5-325 mg 1 tab by mouth every 6 hours as needed for pain. Record review of a progress note dated 07/20/23 at 1:47 p.m., completed by LVN B, indicated Resident #1's family members asked for pain medication for delayed pain. Record review of Resident #1's MAR dated 07/20 23 indicated hydrocodone-acetaminophen oral tablet 5-325 (combination medication is used to relieve moderate to severe pain) was documented as unknown 455952 Page 18 of 19 455952 08/28/2023 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0755 by LVN B at 1:40 p.m. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's narcotic control sheet dated 07/20/23 indicated LVN B dispensed 1 tab of hydrocodone/APAP (acetaminophen) 5/325 mg and then documented the medication as wasted. Residents Affected - Few During an interview on 07/27/23 at 11:37 a.m., LVN B said Resident #1 had fallen out of her wheelchair and after CNA D put her in her bed, Resident #1 began complaining of pain. She said she was preparing the morphine for administration when the family arrived. She said the family did not want the morphine so she took it back to discard and then the family changed their mind because she had explained how it was short acting. She said she returned to Resident #1's room and administered the morphine. She said she returned to the nurse station. She said the family wanted to give Resident #1 more pain medication. She said a family member came to the nurse station and asked for more pain medication. She gave a family member the hydrocodone in a med cup to take to Resident #1. She said should not have given the medication to a family member to administer to Resident #1. She said she was inserviced on 07/20/23 on proper medication administration and written up for the incident. During an interview on 07/27/23 at 11:58 a.m., a family member said the first call from the facility was on 07/20/23 at 12:23 p.m. and she was informed of Resident #1's fall. She said she arrived at the facility about 1 hour later and Resident #1 was screaming. She said there was no staff in the room. She said Resident #1 was in her bed. She said the fall mat was rolled up and against the wall. She said another family member was sent to the nurse station to ask for pain medications. She said the other family member brought a hydrocodone in a medication cup. She said it was totally inappropriate and decided Resident #1 needed 911. She said Resident #1 was left alone in her room and fell from the Geri-chair. During an interview on 07/27/23 at 12:28 p.m., a second family member said she went to the nurse station to tell LVN B that Resident #1 needed pain medication. She said LVN B went to the nurse cart, unlocked the cart, and dispensed a hydrocodone into a medication cup. She said LVN B gave her the medication cup with the hydrocodone to give to Resident #1. She said she took the medication to Resident #1's room and gave it to another family. She said Resident #1 would not take the medication and the other family member took the hydrocodone to the Administrator and informed the Administrator that LVN B had given the hydrocodone to a family member to administer to Resident #1. During an observation on 07/27/23 at 1:45 p.m. (with the Administrator present) of the facility video recording, Resident #1's family arrived on 07/20/23 at 1:00 p.m. At 1:29 p.m. LVN B was at the medication cart, unlocked the control medication, dispensed medication into a medication cup, and gave the medication cup to a family member. During an interview on 07/31/23 at 2:02 p.m., the Administrator said it was brought to her attention on 07/20/23 that LVN B had given Resident #1's family member a hydrocodone to administer to Resident #1. She said LVN B was written up on 07/20/23 and inserviced on medication administration. She said it was the facility's expectation medications were administered per policy. She said there was a risk residents would not receive their medications as they should if not administered as required. Record review of the facility's Administering Medications policy dated 2001 (revised April 2019) indicated .Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 455952 Page 19 of 19