Health inspection·January 3, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 one (Resident #1) of four residents reviewed for medications and pharmacy services. The facility failed to administer Resident #1's blood pressure medications-Midodrine in accordance with the physician orders. Resident #1 was administered Midodrine when his blood pressure was out of parameters and the medication was ordered to be held 17 times in November 2023. Additionally, Resident #1's Midodrine was held 13 times in November 2023, but there were no blood pressure readings documented to indicate what his parameters were and if the medication should have been administered. The failure could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status, including low blood pressure, falls, disorientation and physical discomfort. Findings included: Review of Resident #1's Face Sheet dated 12/20/23 reflected he was a [AGE] year old male admitted to the facility on [DATE] with active diagnoses including end-stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed he had no hearing, speech or vision issues, his BIMS score was 10 which indicated moderate cognitive impairment and he had mood issues related to concentration, fatigue, depression and moving/speaking slowly. Resident #1 had no behaviors, rejection of care, delirium or psychosis. Resident #1 required extensive physical assistance of one staff for all ADLs, he had range of motion impairment on both sides of his lower extremities and used a wheelchair for ambulation. Resident #1 was prescribed and administered during the assessment period insulin, antipsychotic, antidepressant, IV medication and he was a dialysis patient. Review of Resident #1's care plan initiated on 03/17/21 and last revised 10/20/23 reflected, [Resident #1] is at risk for Hyper/hypotensive episodes Hypertension, Orthostatic hypotension. Has orders for midodrine (Date Initiated: 03/17/2021) .Goals: Check blood pressure as ordered and notify MD of Page 1 of 13 675034 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0755 Level of Harm - Minimal harm or potential for actual harm results, Midodrine parameters: Administer if SBP greater than 160 or DBP greater than 90, Observe for S/S of hypotensive episodes, provide medications as ordered. Record review of Resident #1's November 2023 Physician Orders indicated he was prescribed Midodrine 5 mg three times a day for hypotension; Hold for SBP more than 110, no dose in the evening after dinner. Residents Affected - Some Review of Resident #1's November 2023 MAR reflected the following: 1) On the following dates, Midodrine was documented as held and not given due to being out of parameters with no actual blood pressure reading listed on the MAR or in the clinical chart: -8:00 AM on 11/03/23, 11/07/23, 11/09/23, 11/11/23, 11/12/23, 11/15/23, 11/16/23, 11/17/23 and 11/22/23. -Noon on 11/09/23, 11/11/23 and 11/12/23 -4:00 PM on 11/20/23 2) On the following dates, Midodrine was documented as being given when Resident #1's blood pressure reading was over 110 and the medication should have been held per physician's orders: -8:00 AM on 11/04/23 (BP 121/62), 11/05/23 (BP 126/67), 11/20/23 (BP 115/49), 11/24/23 (BP 125/53), 11/25/23 (BP 134/67) and 11/26/23 (BP 122/63) -Noon on 11/04/23 (BP 121/62), 11/05/23 (BP 126/67) -4:00 PM on 11/01/23 (BP 128/59), 11/03/23 (BP 125/61), 11/04/23 (BP 128/71), 11/5/23 (BP 126/67), 11/07/23 (BP 135/88), 11/09/23 (BP 126/66), 11/14/23 (BP 117/51) and 11/25/23 (BP 131/64) Record review of Resident #1's nursing progress notes and e-MAR medications administration notes during November 2023 reflected no reason as to why the Midodrine was held with no blood pressure readings to verify if it was needed, nor why it was given on dates when it should have been held due to being out of parameters. There was no indication through the clinical chart that Resident #1 experienced any falls, passed out or had hypotensive related issues during the month of November 2023. An interview with the ADM, DON, ADON and corporate RN on 12/20/23 at 2:30 PM occurred where they were told about the concerns that medications aides and/or nurses were administering Resident #1's Midodrine when it was out of parameters and holding it when there was no blood pressure recorded and he may have needed it. The facility management did not have any answers as to why this occurred but stated they would look into it. After investigator intervention, an interview with ADON A on 01/03/24 at 1:46 PM revealed the medication aide who was most at fault for failing to administer Resident #1's Midodrine correctly was MA B. ADON A stated MA B was counseled and in-serviced on medication administration on 12/20/23. ADON A stated MA B did not have an explanation as most people don't but she did get [surprised look] when I showed her our hold orders versus when we administer. I told her it was for hypotension, not hypertension. We went over documentation with everyone including vitals for med aides. ADON A stated the charge nurses were responsible to ensure the medications were being administered on their shifts 675034 Page 2 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0755 Level of Harm - Minimal harm or potential for actual harm correctly. ADON A stated it was important to administer medications according to parameters because certain medications had peak times and there was a time limit in which the body broke down medications to get the full effect. Therefore, when the medications were being administered outside of the ordered parameters, the facility was putting the resident at risk to have adverse reactions. ADON A stated, So with Midodrine, giving it when it is supposed to be held could result in hypertension, which is not what we want. Residents Affected - Some An interview with the DON on 01/03/24 at 2:10 PM revealed it was important to administer medications according to physician-ordered parameters because it was the physician's order and he/she had written the order for a particular purpose so the blood pressure would not bottom out. The DON stated the parameters were to prevent an issue, like Resident #1's blood pressure going too low which could cause him to be prone to a fall, or like standing up too fast where his blood pressure bottomed out and could cause him to pass out. The DON stated ADON A talked to MA B, and it was basically human error, not paying close enough attention is my gut feeling. The DON stated she and ADON A had the capability of running spot audits through their e-charting system of specific blood pressure medications with parameters and then pulling the MAR for those residents and checking to see if the medication was given correctly but since they were both newer to the facility (DON started in October 2023), it had not been on her radar yet. The DON stated, When you come into a new place, there is so much to look at. An interview with MA B on 01/03/24 at 2:38 PM revealed the facility had not yet talked to her about the discrepancies found with Midodrine being administered to Resident #1 when the medication was out of parameters or being held when it should have been given. MA B stated when she worked with Resident #1, his blood pressure would usually be low, especially when he came back from his dialysis visits. She stated the orders reflected Midodrine could not be given after dinner so if he was at dialysis and did not get back in time, it would have to be held, but if it was a non-dialysis day, then it could be given. MA B stated Resident #1 was more at risk for low blood pressure and the top number (systolic) was the important one to watch; if it was over 100, we should not give it. MA B stated if she gave a medication in error when it should have been held, she would let one of the head ladies know, to include the charge nurse and directors and complete any paperwork they gave her. MA B did not remember giving Resident #1's Midodrine when his blood pressure was out of parameters. Review of the facility's policy titled, Medication Administration (not dated), reflected, Purpose: To provide practice standards for safe administration of medications for residents in the Facility .Policy: .VII. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medication record; .Procedure: VII. The resident's MAR will be reviewed for allergies and/or special considerations for administration including .C. Vital sign parameters and lab results as appropriate .XVI. The Licensed Nurse will chart the drug, time administered and initials his/her name with each medication administration and sing full name and title on each page of the MAR .XVII. Holding Medications-A. Whenever a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The licensed Nurse will document the reason the medication was held on the back of the MAR. 675034 Page 3 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. 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 promptly notify the physician, physician assistant, nurse practitioner, or clinical specialist of the results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification or a practitioner or per the ordering physician's orders for one (Resident #2) of four residents reviews for laboratory services. Residents Affected - Few The facility failed to notify the physician [MD H] of Resident #2's stat x-ray results when she had a change in condition. The x-ray results indicated there were findings. The failure could place residents at risk for not receiving timely medical intervention as needed and ordered by the physician and a potential for decreased health status and discomfort. Findings included: Record review of Resident #2's Face Sheet dated 01/03/24 reflected she was a [AGE] year-old female who admitted to the facility on [DATE] with the primary diagnosis of heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) as well as secondary diagnoses of vascular dementia (dementia caused when decreased blood flow damages brain tissue), mild intellectual disabilities (a term used when there are limits to a person's ability to learn at an expected level and function in daily life), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and atrial fibrillation (when the heart's upper chambers called the atria, beat chaotically and irregularly). Review of Resident #2 quarterly MDS assessment dated [DATE], reflected she had no hearing issues, but did have unclear speech, sometimes understood others, had impaired vision, long and short term memory problems and was severely impaired in her cognitive skills for daily decision making. Resident #2 had no delirium, mood issues or behaviors, including rejection of care. Resident #2 had no assessed health conditions related to shortness of breath. Resident #2's height was five foot five and she was 391 pounds. She was not on any oxygen therapy at the time of the MDS assessment. Review of Resident #2's care plan (undated) reflected she had congestive heart failure and was at risk for shortness of breath related to her congestive heart failure. Interventions included to check breath sounds for labored breathing and monitor/document/report to MD PRN any s/sx of Congestive Heart Failure .shortness of breath upon exertion and monitor lab work and ex-rays as needed. Record review of the following pertinent nursing notes for Resident #2 revealed: -12/18/2023 at 2:11 PM- Resident noted with cough and SOB, [MD H] notified with chest x-ray ordered/[POA] notified )O2 sats at 94%. -12/18/23 at 5:30 PM- (Late Entry) Chest x-ray performed by [company name], resident tolerated well was sitting upright, awaiting for the results. -12/19/23 7:42 AM- Nurse perform COVID test with negative results. 675034 Page 4 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -12/19/23 9:30 AM-Ambulance service here, transported to [hospital], [POA] here, [MD] aware, chest x-ray modest cardiomegaly (enlarged heart)with modest congestive heart failure. Oxygen in use for respiration distress. 120/82 (blood pressure) 98.9 (temperature) 93% (oxygen saturation level) P=113 (pulse) R=22 (respirations). Record review of nursing progress notes for 12/18/23 and 12/19/23 reflected no indication the physician was notified of Resident #1's chest x-ray results. A late entry nursing progress note was entered after investigator intervention on 12/20/23 at 11:46 AM by ADON A which stated, CXR ordered, [MD H] notified, [POA] notified of new orders. V/S within normal limits. O2 sat @94%. [Radiology company] arrived to perform CXR. Resident tolerated CXR well. No s/sx of any respiratory distress at that time. Chest x-ray resulted in moderate cardiomegaly and moderate CHF. Record review of Resident #2's physician order dated 12/18/23 reflected, X-ray 2 views d/t cough and sob. Record review of Resident #2's x-ray-Chest 1 view dated 12/18/23 reflected the imaging was taken at 8:00 PM nd the results were ready at 8:58 PM. The findings reflected the heart was modestly enlarged, there was modest pulmonary venous congestion, and the lung fields were without mass or infiltrate and the osseous structure [bone tissue] was unremarkable. The conclusion reflected, Modest cardiomegaly (when the heart is abnormally thick or overly stretched, becoming larger than usual, with difficulty pumping blood), with modest congestive heart failure. An interview with Resident #2's POA on 12/20/23 at 12:18 PM reflected on 12/18/23, the speech therapist had notified one of the nurses that Resident #2 was not looking well and was slumped over and seemed to be breathing harder. Then LVN C called the POA and notified her and said she was going to order an x-ray and someone would contact the POA later that night with the results. The POA did not hear back from anyone, so the next morning [12/19/23], she went to the facility and when she saw Resident #2, she was in bed on her stomach, which was unusual for her because she was very overweight. The POA stated she asked the staff if they had seen the change in her and why they did not call the POA because she wanted her sent out. The POA stated the staff told her Resident #2 was refusing to put on oxygen before the POA arrived. The POA told them why did they not call her when Resident #2 refused, they knew she would come up there to help. The POA stated when Resident #2 got to the hospital, she had a fever and the medical staff thought she had a UTI. The POA was upset the facility did not act faster and said Resident #2 had the mindset of a six year old and could not advocate for herself, talk and tell people how she felt. The POA stated she was told the facility's x-ray reflected Resident #2 had cardiomegaly, which was an enlarged heart, but nothing about her having fluid on her lungs of which she was incredulous. She stated Resident #2 had been placed on Lasix at the hospital to decrease the fluid on her lungs and she was currently on 4 lpm of oxygen. An interview with the DON on 12/20/23 at 10:00 AM revealed on the evening of 12/18/23, the charge nurse [LVN D] noticed that Resident #2 was having a change of condition as she did not seem to be breathing as well as she normally did. The charge nurse notified the POA that the doctor ordered a chest x-ray. Results came back around 9pm that same night and there were some findings, mild, not critical. The DON stated, But the error was that the nurse [LVN D] did not contact the doctor to notify him of findings and she did not notify the [family member] of the test results, which she should have done both. The DON stated, Even if the chest results were normal, or mild, the doctor still needed to be notified because that is his patient and a test he ordered. He would need to know what the findings were to see if there were any other course of action to take. The DON said when ADON A counseled LVN D on 12/20/23, she did not have an excuse, and just said she forgot. The DON stated when 675034 Page 5 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0777 Level of Harm - Minimal harm or potential for actual harm Resident #2's POA came to see her the next morning on 12/19/23 around 8:30 AM, the POA felt she was not responsive and was acting different. The DON stated Resident #2's vitals had been taken per clinical documentation about 15 minutes prior to her POA making that comment and were all within normal limits; her oxygen saturation was 92 on room air, but we went ahead and put oxygen at 3 lpm on the resident and the RP wanted her sent out to the hospital. Residents Affected - Few An interview with LVN C on 12/20/23 at 11:07 AM revealed she was the 6AM-2PM charge nurse for Resident #2's hall. LVN C stated when she got to work around 6:00 AM on 12/18/23, the overnight nurse [LVN D] had been trying to place PRN oxygen on Resident #2 for shortness of breath. LVN C stated she did observe Resident #2 to have some respiratory issues, but it must have been suddenly because she did not present like that the day before. LVN C stated, She was breathing normally, but just harder. LVN C stated Resident #2 was not letting the overnight nurse [LVN D] give her a breathing treatment or keep the oxygen on her face. LVN C stated after that, she contacted MD H and obtained a stat chest x-ray order but the radiology company did not come out to take images on her shift and she completed a COVID test which was negative. Around 6:45 PM, she texted LVN D about Resident #2 and asked if she had received the results, with no response. Later that evening, on 12/18/23, LVN C stated she called up to the facility and asked LVN D if Resident #2's chest x-ray had been taken and LVN D told her the company had come around 8:30 PM on that evening to take the images with no results yet. LVN C stated the next morning (12/19/23) when she came to work, Resident #2 was still having shortness of breath and she asked the overnight nurse [LVN D] about the x-ray results but LVN D told her she had not received them and was waiting for them to be sent over. LVN C stated she then went into the computer lab database and was able to locate it. She stated the x-ray report showed Resident #2 had modest cardiomegaly, meaning she had heart issues anyway. LVN C stated when she read a resident's chest x-ray, she was looking to see if the report told her something was going on. For Resident #2, she could not remember what it said, but something was going on. LVN C stated she wanted to send Resident #2 to the hospital based on the x-ray results and told MD H that was what she wanted because Resident #2 was having difficulty breathing and let him know what the x-ray results were at that time and he agreed. LVN C stated she and ADON A tried to put oxygen on Resident #2, but she would not cooperate and would pull the nasal cannula out. Then she said ADON A put a rebreather (a breathing hose) on Resident #2 and the resident allowed that to stay in place. LVN C stated the POA arrived at the facility during the time breakfast trays were being served. because the POA was concerned that no one had called her back to let her know what the chest x-ray results were from the day before and she was concerned about Resident #2. At that point, EMS arrived and Resident #2 was taken to the hospital. LVN C stated that she had talked to Resident #2's POA the morning of 12/20/23 and the POA informed her the resident was still in the hospital and had fluid on her lungs and was on an IV for a UTI. LVN C stated while Resident #2 was at the facility prior to being sent out on 12/19/23, she did not have a fever and her vitals were not abnormal. LVN C stated when a resident's x-ray results came in, the doctor was supposed to be notified immediately, even if the results were normal, the charge nurse would still notify the doctor by the end of the shift. The x-ray results were online so the charge nurse was able to check them. If it could have been differently, LVN C stated it would have been nice if when the x-ray was completed, the facility nurse would have gotten the report a little sooner. However, LVN C stated if she thought Resident #2 was in imminent distress, she would have sent her out earlier, but her vitals were normal and her COVID test was negative. An interview with ADON A on 12/20/23 at 11:40 AM revealed the overnight nurse [LVN D] was new to the facility and she had already done correction counseling with her about the chest-x-ray results not being checked timely and MD H not being notified sooner. ADON A 675034 Page 6 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated LVN D should have checked the results of the chest x-ray and seen that the results had come in the night before and notified the doctor, this is protocol. The doctor needs to be notified to see if there is any additional tests or treatment decisions that need to be made. ADON A read the chest x-ray results at the time of the interview and the conclusion was that Resident #2 had congestive heart failure, which the facility already knew, her vitals were within normal limits and she did not present with anything other than labored breathing, but her oxygen saturation was in the 90's. An interview with MD H on 12/20/23 at 12:34 PM revealed the only involvement he had with Resident #2 was the attending nurse (name unknown) called and said Resident #2 had a change in vitals on 12/19/23 and while he did think the changes were significant enough to send her out, the family wanted to be sent her out so that was what he did. He stated the reason he had ordered a chest x-ray was to rule out pneumonia. MD H stated, If I am recalling right, there were some slight changes [in the chest x-ray] and I wanted to treat in-house with breathing treatments because it wasn't confirming pneumonia or infection, so I wanted to see if it would clear up with breathing treatments. MD H stated Resident #2's oxygen saturation levels were not that significant so he wanted to see if her symptoms would improve and the repeat chest x-ray and evaluate ongoing. MD H stated Resident #2's chest x-ray had come in the evening of 12/18/23 and usually a nursing home would call him with the results immediately, even if they were normal. MD H stated if he had received Resident #2's chest x-ray results that same evening, his decision making would have probably included, even if her chest x-ray was clear and her O2 sats were good, I go ahead and treat with breathing treatment to give some relief and feel less hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions) which could have been started the night before possibly, if I would have known. In my opinion, I think if the patient's vitals are good and no change in O2 sats, that is a big deal, then that is a non-emergency type of thing, just to follow up kind of thing. MD H stated he did not know if fluid on the lungs would have shown up in a chest-x-ray, but he did not see the actual results, he said he had to rely on what the nurses told him at the facility because he did not have access to the e-database they used for x-rays. An interview with the DON on 01/03/24 at 12:21 PM revealed Resident #2 was back from the hospital and was doing fine. Observation and attempted interview of Resident #2 occurred on 01/03/24 at 1:38 PM. Resident #2 was observed in her room sitting in a chair next to her bed watching television. She was not responsive to the investigator's questions and would not make eye contact. As a result, Resident #2 was unable to be interviewed. She was observed to be dressed appropriate, her disposition suggested no breathing issues and she appeared engrossed in her television show. An interview with ADON A on 01/03/24 at 1:46 PM revealed when a resident had an x-ray ordered, if it had to do with an acute change of condition, the nurse should fill out an E-Interact Change of Condition Form and call the RP to let them know what was happening, do a progress note and document when the radiology company came to the facility and did the x-ray. After that, the nurse should call the physician and RP when the results come in and document any new orders. ADON A stated since the incident, the facility had implemented a new monitoring process for x-rays and felt it had worked well. ADON A stated it was important for x-ray results to be communicated to the physician because, I am the eyes for the doctor because he can't be here. Can I interpret a lab or diagnostic? Yes. Can I give myself orders for it? No, which is why we notify the doctor after we receive the results. ADON A stated the physician should be notified by nursing judgement, meaning if a lab came in around 9 PM at night and it was normal based off the resident's baseline, then no, she would not call the physician that late. However, if she was following up on an order received prior to her shift, then she 675034 Page 7 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0777 would have to take responsibility and notify the physician immediately. Level of Harm - Minimal harm or potential for actual harm An interview with the DON on 01/03/24 at 2:10 PM revealed when an x-ray result came in, she expected the report to be in within the next two to three hours because it had to be read. The results came through the e-charting system database and the nurses could see them. The DON stated the charge nurse should know there was an x-ray report waiting to be read because of receiving report from the off going nurse at change of shift. If the x-ray results were normal, the charge nurse should call the physician and let them know and see if they want any further orders. With Resident #2 specifically, the DON stated she was a person with a history of congestive heart failure, so most of the time her chest x-rays would come back showing moderate cardiomegaly. If the results had reflected a severe or high amount of heart failure or fluid, the DON said that would be extremely abnormal, however, the doctor should have been notified anyway. She said he may have wanted to increase Resident #2's breathing treatments, maybe provide some PRN oxygen, You [charge nurse] are pushing it off to the doctor to let him make that decision. The DON stated once she talked to MD H, he said he would not have done anything different. The DON stated LVN resigned after the incident. Residents Affected - Few An interview was attempted with LVN D via phone on 01/03/24 at 2:20 PM with no answer. A voice mail was left with no response. Review of the facility's policy titled, Laboratory, Diagnostic and Radiology Services, revised June 2020, reflected, Procedure: .III. The ordering physician will be notified of the results that fall outside of clinical reference or expected normal ranges per the ordering practitioner's order.; .C. The Licensed Nurse will document the time when the results were reported to the ordering practitioner and the ordering practitioner's response or additional orders, if any. 675034 Page 8 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview and record review, the facility failed to ensure that in accordance with accepted professional standard and practices, medical records were complete and accurately documented for two (Residents #2 and #3) of three residents reviewed for clinical records accuracy. The facility failed to document Resident #2 and Resident #3 received their medications during the 6:00 AM-2:00 PM shift on Sunday, 12/17/23. The facility failure could place residents at risk of inaccurate medication administration and inaccurate clinical records that could lead to medication errors and poor health management control. Findings included: 1. Record review of Resident #2's Face Sheet dated 01/03/24 reflected she was a [AGE] year old female who admitted to the facility on [DATE] with the primary diagnosis of heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) as well as secondary diagnoses of vascular dementia (dementia caused when decreased blood flow damages brain tissue), mild intellectual disabilities (a term used when there are limits to a person's ability to learn at an expected level and function in daily life), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), atrial fibrillation (when the heart's upper chambers called the atria, beat chaotically and irregularly), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), anemia (a condition that develops when the blood produces a lower-than-normal amount of healthy red blood cells), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), chronic embolism and thrombosis of deep veins (a clot that over one to town months old), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces) and edema (swelling caused by too much fluid trapped in the body's tissues). Review of Resident #2 quarterly MDS assessment dated [DATE], reflected she had no hearing issues, but did have unclear speech, sometimes understood others, had impaired vision, long and short term memory problems and was severely impaired in her cognitive skills for daily decision making. Resident #2 had no delirium, mood issues or behaviors, including rejection of care. Resident #2 was prescribed and received antipsychotic medication, an antidepressant, anticoagulant, diuretic (substance that increases production of urine)and hypoglycemic (low blood sugar) medication during the MDS assessment period. Review of Resident #2's December 2023 physician's orders reflected she was prescribed the following medications: -CoQ10 Oral Capsule 100 MG one tablet by mouth one time a day for supplement (start date 03/31/23) -Digoxin Tablet 0.25 MG by mouth one time a day for atrial fibrillation (HOLD HR LESS THAN 60) (start date 07/13/18) 675034 Page 9 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0842 -Ferrous Sulfate Tablet 325 MG one tablet by mouth one time a day for supplement (Start date 03/28/19) Level of Harm - Minimal harm or potential for actual harm -Imdur Tablet Extended Release 24 Hour 30 MG one tablet by mouth one time a day related to essential primary hypertension (HOLD FOR SYSTOLIC BLOOD PRESSURE <120 OR DIASTOLIC BLOOD PRESSURE <60 OR PULSE <60) (start date 11/01/17) Residents Affected - Few -Lisinopril Tablet 5 MG one tablet by mouth one time a day related to essential hypertension (HOLD FOR SBP LESS THAN 120 OR DBP LESS THAN 60 OR PULSE LESS THAN 60) (start date 06/29/17) -Multivitamin with Iron one tablet by mouth one time a day for supplement (start date 07/18/18) -Olanzapine Tablet 7.5 MG one tablet by mouth one time a day related to bipolar disorder, amnic, severe with psychotic features (start date 05/11/22) -Synthroid Tablet 100 MCG one tablet by mouth one time a day related to hypothyroidism (start date 07/01/23) -Wellbutrin XL Tablet Extended Release 24 Hour 150 MG one tablet by mouth one time a day for major depression (start date 01/03/23) -Carvedilol Tablet 25 MG give 1.5 tablet by mouth two times a day related to unspecified atrial fibrillationHold for Systolic Blood Pressure less than 120 or Diastolic Blood Pressure less than 60 or Pulse less than 60. Give 1&1/2 tabs of 25mg to equal 37.5mg twice a day (start date 10/13/20) -Diamox Sequels Capsule Extended Release 12 Hour 500 MG give one capsule by mouth two times a day related to papilledema associated with increased intracranial pressure (start date 08/17/20) -Docusate Sodium Capsule 100 MG give one capsule by mouth two times a day for constipation (start date 01/27/17) -Eliquis Tablet 5 MG give one tablet by mouth two times a day related to chronic atrial fibrillation (start date 01/27/17) -Metformin Extended Release 24 Hour 500 MG give one tablet by mouth two times a day for diabetes (start date 11/07/22) -Potassium Chloride Extended Release 20 MEQ give one tablet by mouth two times a day for Supplement (start date 11/03/21) -Torsemide Tablet 20 MG give two tablets by mouth two times a day related to heart failure (start date 10/25/18) Record review of Resident #2's December 2023 MAR revealed the morning administration doses of 7AM, 8AM and 9AM for her medications were blank and did not reflect they were given. The medications were CoQ10, Digoxin, Ferrous Sulfate, Imdur, Lisinopril, Multivitamin with Iron, Olanzapine, Synthroid, Wellbutrin, Carvedilol, Diamox Sequels, Docusate Sodium, Eliquis, Metformin, Potassium Chloride, Torsemide. 675034 Page 10 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #2's nursing progress notes and e-MAR administration notes for 12/17/23 did not reflect the medications were given and there was no note to indicate why they were not administered as ordered. Observation and attempted interview of Resident #2 occurred on 01/03/24 at 1:38 PM. Resident #2 was observed in her room sitting in a chair next to her bed watching television. She was not responsive to the investigator's questions and would not make eye contact. As a result, Resident #2 was unable to be interviewed. 2. Record review of Resident #3's Face Sheet 01/03/24 reflected he was a [AGE] year old male admitted to the facility on [DATE] with active diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Secondary diagnoses included muscle contracture, hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness), cerebrovascular accident affecting right dominant side and left non-dominant side (a stroke -an interruption in the flow of blood to cells in the brain), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), anxiety (a feeling of fear, dread, and uneasiness), presence of coronary angioplasty implant and graft (a procedure used to widen blocked or narrowed coronary arteries), malnutrition (lack of sufficient nutrients in the body), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), emphysema (a type of lung disease that causes breathlessness), respiratory failure (a serious condition that makes it difficult to breathe on your own), alcohol-induced pancreatitis (the redness and swelling (inflammation) of the pancreas), hypercapnia (when you have high levels of carbon dioxide in your blood), and absence of right leg above knee. Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected a BIMS score of 14, with indicated no cognitive impairment. Resident #3 has no hearing or vision issues, no delirium or psychosis, no wandering or rejection of care. Resident #3's MDS reflected he was not prescribed and did not take any high-risk medications. Record review of Resident #3's December 2023 physician's orders reflected he was prescribed the following medications - Aspirin 81 Oral Tablet Chewable one tablet by mouth one time a day related to presence of coronary angioplasty implant and graft (start date 03/23/23) -Atorvastatin Calcium Tablet 40 MG one tablet by mouth one time a day for Hyperlipidemia (start date 07/02/22) -Magnesium Oxide Tablet 400 mg by mouth one time a day for supplement (start date 07/02/22) -Namenda Tablet 10 MG one tablet by mouth one time a day related to dementia (start date 09/30/22) -Potassium Chloride Extended Release 10 MEQ one tablet by mouth one time a day for supplement (start date 07/02/22) -2.0 Supplement three times a day related to cerebral infarction give 120ml after meals (start date 675034 Page 11 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0842 08/19/22) Level of Harm - Minimal harm or potential for actual harm -Midodrine HCl Tablet 5 MG one tablet by mouth three times a day for low blood pressure- Hold if systolic >110 or diastolic >60 (start date 11/29/22). Residents Affected - Few Record review of Resident #3's December 2023 MAR revealed the morning administration doses of 7AM, 8AM and 9AM for his medications were blank and did not reflect they were given. The medications were Aspirin, Atorvastatin, Magnesium Oxide, Namenda, Potassium Chloride, 2.0 Supplement and Midodrine. Record review of Resident #3's nursing progress notes and e-MAR administration notes for 12/17/23 did not reflect the medications were given and there was no note to indicate why they were not administered as ordered. 3. An interview with ADON A on 12/20/23 at 1:30 PM revealed she had already noticed that the nurse who worked the morning on 12/17/23 was LVN F and she did not document she administered medications on the hall she was working-100 hall. ADON A stated there was usually a medication aide who passed medication but she was out sick that morning and could not work. ADON A stated all the nurses knew they had to document when they passed resident medications or the e-charting system would think it did not happen. ADON A stated, I think she probably was busy and just did not document, but that is not an excuse. They have to document when medications administered. An interview with LVN F on 12/20/23 at 3:23 PM revealed she was the charge nurse working on Resident #2 and Resident #3's hall on the 6AM-2PM shift on 12/17/23. She stated as a nurse, that morning she had about 12 to 14 residents who required blood sugar checks and insulin which she was responsible for, one resident with a g-tube whom she had to administer medications to, and one resident on an IV antibiotic she had to take care of. LVN F stated she started her day in the dining room from 7:30 AM to 8:30 AM to make sure none of the residents choked, then she went to disconnect a resident's g-tube and gave medications to that resident, then take care of a wound treatment for another resident, then gave PRN pain medications including pain assessments. LVN F did not know who was assigned to be her medication aide that day but no one showed up for the morning shift. LVN F stated the wound care nurse was working and passed medications on her hall, but the wound care nurse was also training another nurse on the medication cart (there was only one for the facility aside from the secured unit's cart), so they had to share the med cart. LVN F stated the wound care nurse did not pass medications on LVN F's hall 100. LVN F stated she usually had 26-32 residents to take care of on a Sunday weekend double shift (6AM-6PM). LVN F stated she did pass medications on 12/17/23, but it was not in the morning because the wound care nurse took the medication cart (med aide cart) so she could pass her medications on her halls first and she was training another nurse. LVN F stated, I did give some their meds, I pulled them that needed them .based on high acuity. I didn't miss any of my residents. I may not have given them on time but I didn't miss them. I didn't document because the techs come and get the computer off the cart so they can chart. LVN F said because the wound care nurse was using the only medication cart, she had to wait until the wound care nurse passed her meds, so LVN F could administer to her residents. LVN F stated when she administered the resident medications on Hall 100, she did not have a computer to use, so I thought I documented when I came to sit back down. LVN F stated the facility called for a medication aide who was able to come around 4:00 PM to help pass medications on 12/17/23. An interview with ADON A on 01/03/24 at 1:46 PM revealed she had spoken with LVN F about the blank MARs on 12/17/23 and LVN F thought she had completed the MAR documentation and said she administered all the residents' medications. ADON A said she went over with her if it was not documented, it 675034 Page 12 of 13 675034 01/03/2024 Arbor Lake Nursing & Rehabilitation, LLC 901 Pennsylvania Ave Fort Worth, TX 76104

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few didn't happen. ADON A stated before the investigator intervention, as the newer ADON to the facility, her process to monitor MAR was to only look at the MARs every morning on the online clinical dashboard at the facility because she did not have remote access to view anything until the past weekend (12/30/23). Now that she had remote access, ADON A stated she and the DON would take their computers home every day and check at the end of the shifts to ensure resident medications were given. If they did not show as administered, then she would call the facility nurse/medication aide to see what happened and follow up in order to get a better hold of MAR documentation. An interview with the DON on 01/03/24 at 2:10 PM revealed LVN F had been counseled and they talked to her about medications and they had to be given and she should have known from the beginning of her shift that the medication aide was not going to be there and she should have prioritized her tasks. The DON stated, That is what a prudent nurse should do and in the future when a med aide doesn't show up, we try to replace anyone that calls in and the ADON was already here working, so that was the person on call who was at the facility helping and what she [LVN F] could have done was ask for help versus the poor pitiful me, I am doing the best I can. The DON stated the e-charting system did not alert nursing management when a medication was missed, but nursing management was able to run an audit to see what medications were not administered but it was not a routine practice for oversight. The DON stated she was new to the facility and putting practices in place and going forward, the nursing management was going to review any missed medications on Monday for the weekend prior, and on Fridays, for the week prior. 4. Review of the facility's policy titled, Medication Administration (not dated), reflected, Purpose: To provide practice standards for safe administration of medications for residents in the Facility .Policy: .VII. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medication record; .Procedure: VII. The resident's MAR will be reviewed for allergies and/or special considerations for administration including .C. Vital sign parameters and lab results as appropriate .XVI. The Licensed Nurse will chart the drug, time administered and initials his/her name with each medication administration and sing full name and title on each page of the MAR. 675034 Page 13 of 13