Health inspection·March 13, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 18 residents reviewed for resident assessment (Resident #68). Residents Affected - Few The facility did not have an accurate PASRR level 1 screening (PL1) for Resident #68 upon admission date of 05/12/23. This failure could place residents who have a diagnosis of mental disorder, developmental disability, or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a face sheet dated 03/11/24 indicated Resident #68 was a [AGE] year-old male admitted [DATE] with diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement including tremors) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Record review of an admission MDS dated [DATE] indicated Resident #68 was not PASSR positive and had a BIMS score of 12 indicating moderately impaired cognition. The MDS indicated Resident #68 had diagnoses of Parkinson's disease and schizophrenia and received an antipsychotic medication 7 of 7 days. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #68 had a BIMS score of 15 indicating intact cognition. He had diagnoses of Parkinson's disease and schizophrenia and received an antipsychotic medication. Record review of a care plan dated 05/15/23 indicated Resident #68 had a care plan indicating he was PASRR positive and would receive any PASRR service recommended. Record review of physician's orders dated 03/12/24 indicated Resident #68 was prescribed fluphenazine HCL (an antipsychotic medication to treat schizophrenia) 2.5 mg two times a day for schizophrenia with a start date of 11/27/23. Record review of a PASRR level 1 screening completed by the transferring facility dated 05/11/23 indicated Resident #68 was negative for mental illness, intellectual disability, and developmental disability and negative for dementia as the primary diagnosis. There was no PASRR Level II Screening or Page 1 of 6 455952 455952 03/13/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0645 Level of Harm - Minimal harm or potential for actual harm Form 1012 (Mental Illness/Dementia Resident Review) found in the clinical record from the resident's admission on [DATE] to 03/12/24. During an observation and interview on 03/11/24 at 09:48 a.m., Resident #68 was lying in bed with no observed distress. He said he was treated well and received needed care. Residents Affected - Few During an interview on 03/12/24 02:10 p.m., MDS Nurse B said she completed Resident #68's PL1s and MDS' part time. She said she did not enter Resident #68's PL1 or MDS and was unaware he had a negative PL1. She said with his diagnosis he should have had a positive PL1. MDS Nurse B said it was overlooked. MDS Nurse B said Resident #68's PL1 should have been corrected before now. MDS Nurse B said the risk to residents of a PL1 form incorrect was a resident would not receive services he was entitled to. During an interview on 03/12/24 at 12:00 p.m., MDS Nurse A said she started in January 2024 and was now responsible for PASRR forms. She said MDS Nurse B was her backup. She said she was educated on PASSR forms. After Surveyor F intervention, MDS Nurse A completed a 1012 form and uploaded a new positive PL1 into the Long-Term Care system for Resident #68. MDS Nurse A said the risk of an incorrect PL1 was a resident could miss out on deserved services. She said Resident #68 received psych services currently. MDS Nurse A said Resident #68's PL1 should have been corrected sooner. During an interview on 03/12/24 2:40 p.m., the DON said MDS Nurses A and B were educated on PASRR forms and were each other's back up. She said MDS Nurse A was ultimately responsible for PASRR forms. She said Resident #68's form was overlooked. The DON said the risk to residents of a PL1 being incorrect was a resident may not receive services they were entitled to. The DON said her expectation was proper screening to determine PASRR eligibility. During an interview on 03/12/24 2:45 p.m., the Administrator said MDS Nurses A and B were educated on PASRR forms and were each other's back up. The Administrator said MDS Nurse A was ultimately responsible for PASRR forms. She said Resident #68's form was overlooked. The Administrator said the risk of a PL1 being incorrect was a resident may not receive services they were entitled to. The Administrator said her expectation was proper screening to determine PASRR eligibility. Record review of the facility policy, revised March 2019, titled, admission Criteria indicated, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. A. The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to determine it the individual meets the criteria for a MD, ID or RD. Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected of having MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. 455952 Page 2 of 6 455952 03/13/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide services as outlined by the comprehensive care plan, to meet professional standards of quality for consultation with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for one (Resident #9) of 18 residents reviewed for following physician's orders. Residents Affected - Few The facility failed to implement Resident #9's care plan when her blood pressure and/or heart rate was below prescribed parameters and did not notify her physician in March 2024. (03/01/24, 03/02/24,03/03/24, 03/04/24, 03/05/24, 03/06/24, 03/08/24, 03/09/24, 03/10/24, 03/11/24, 03/12/24 and 03/13/24). The failure placed residents, who required blood pressure and heart rate monitoring, at risk for complications due to delayed physician intervention. Findings included: Record review of Resident #9's clinical record indicated she was admitted on [DATE], was [AGE] years old with diagnoses which included hypertension (high blood pressure). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #9 had a BIMS score of 09 which indicated cognition was moderately impaired. She had a diagnosis of hypertension. Review of Resident #9's care plan revised on 06/08/23 indicated the resident had diagnosis of hypertension and was at risk for/potential for elevated blood pressure. The interventions included monitoring vital signs as ordered and notifying MD (medical doctor) of significant abnormalities Record review of physician orders dated March 2024 indicated Resident #9 was prescribed amlodipine besylate 10 mg (used to lower blood pressure) daily for hypertension. Hold if blood pressure reading was below 110/60 and heart rate below 60. Record review of the MAR dated March 1 - 13, 2024 indicated on the following dates at 9:00 a.m., Resident #9's amlodipine besylate was held and there was no indication in the clinical record the physician had been notified: 03/01/24, 03/02/24, 03/03/24, 03/04/24, 03/05/24, 03/06/24, 03/08/24, 455952 Page 3 of 6 455952 03/13/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0658 03/09/24, Level of Harm - Minimal harm or potential for actual harm 03/10/24, 03/11/24, Residents Affected - Few 03/12/24; and 03/13/24. There were no recorded vital signs of Resident #9's on the March 2024 MAR. Record review of nurse's notes for Resident #9 dated March 1 through March 12, 2024, gave no indication of notifying the physician of the blood pressure medication being held for 12 of 13 opportunities. During an interview and record review on 03/13/24 at 8:15 a.m., MA C said she took the resident's vital signs prior to medication administration, and she would document on a piece of paper and gave them to the charge nurse following the morning medication pass. She said the was no designated area on the electronic record to document blood pressure or heart rate on a resident's individual MAR. MA C was said she was unsure what the charge nurses did with the vital signs, and there should be an area on the electronic MAR to document resident's vital signs. During an interview and record review on 03/13/24 at 8:40 a.m., LVN D and LVN E reviewed Resident #9's current electronic MAR and acknowledged the absence of a place for documentation of vital signs. They both said they had thought all residents' vital signs were documented on their MAR and acknowledged Resident #9's MAR lacked an area for documentation and should have been documented. LVN E said anytime a resident had vital signs out of parameters, the physician should be notified, especially if there was a pattern of medications being withheld. LVN D said the physician for Resident #9 should be notified and made aware of consistent withholding of the blood pressure medications. During an interview and record review on 03/13/24 at 9:08 a.m., the DON said her expectations were for residents with prescribed parameters for administration of medications to have documentation of those vital signs. She added she will conduct chart audits and it was her responsibility to assure accuracy of resident's clinical records. She acknowledged Resident #9's March MAR did not have vital signs documented and should have. The policy Administering Medications dated April 2019 indicated . If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 455952 Page 4 of 6 455952 03/13/2024 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 interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 18 residents reviewed for medication administration. (Resident #9) The facility did not document blood pressure or heart rate for Resident #9 on the MAR, before administering medications with orders that included instructions to hold for prescribed parameters. This deficient practice failure could place residents with prescribed medication parameters at risk of not receiving the desired therapeutic effects of their medications. Findings included: Record review of Resident #9's clinical record indicated she was admitted on [DATE], was [AGE] years old with diagnoses which included hypertension (high blood pressure). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #9 had a BIMS score of 09 which indicated cognition was moderately impaired. She had a diagnosis of hypertension. Review of Resident #9's care plan revised on 06/08/23 indicated the resident had diagnosis of hypertension and was at risk for/potential for elevated blood pressure. The interventions included monitoring vital signs as ordered and notifying the MD (medical doctor) of significant abnormalities. Record review of physician orders dated March 2024 indicated Resident #9 was prescribed amlodipine besylate 10 mg (used to lower blood pressure) daily for hypertension. Hold if blood pressure reading was below 110/60 and the resident's heart rate below 60. Record review of the MAR dated March 1 - 13, 2024 indicated on the following dates at 9:00 a.m., Resident #9's amlodipine besylate was held and there was no indication in the clinical record of blood pressure or heart being obtained prior to administration of medications: 03/01/24, 03/02/24, 03/03/24, 03/04/24, 03/05/24, 03/06/24, 03/08/24, 03/09/24, 455952 Page 5 of 6 455952 03/13/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0755 03/10/24, Level of Harm - Minimal harm or potential for actual harm 03/11/24, 03/12/24; and Residents Affected - Few 03/13/24. Record review of nurse's notes for Resident #9 dated March 1 through March 12, 2024, gave no indication of daily blood pressure or heart rate documentation. During an interview and record review on 03/13/24 at 8:15 a.m., MA C said she takes the resident's vital signs prior to medication administration and documents on paper and gives them to the charge nurse following the morning medication pass. She said the was no designated area on the electronic record to document blood pressure or heart rate on resident's individual medication administration record. MA C was said she was unsure what the charge nurses do with the vital signs, and there should be an area on the electronic MAR to document resident's vital signs. During an interview and record review on 03/13/24 at 8:40 a.m., LVN D and LVN E reviewed Resident #9's current electronic MAR and acknowledged the absence of documentation of vital signs. They both said they had thought all resident's vital signs were documented on their MAR and acknowledged Resident #9's MAR lacked an area for documentation and should have been documented. During an interview and record review on 03/13/24 at 9:08 a.m., the DON said her expectations were for residents with prescribed parameters for administration of medications to have documentation of those vital signs. She added she will conduct chart audits and it was her responsibility to assure accuracy of resident's clinical records. She acknowledged Resident #9's March 2024 MAR did not have vital signs documented and should have. The policy Pharmacy Services Overview dated April 2019 indicated . Medications are received, labeled, stored, administered, and disposed of according to all applicable state and federal laws and consistent with standards of practice. 455952 Page 6 of 6