Health inspection·September 13, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review; the facility failed to provide pharmaceutical services that included the accurate acquiring and receiving of all drugs and biologicals to meet the needs of each resident noted in 1 of 3 medication areas (medication room) reviewed for medication storage. The facility medication room contained 3 prescription medications that were expired. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes. Findings include: During an observation on 09-12-2023 at 09:31 AM of the facility's medication room with the DON and CRN present the following medications were noted to be expired that were present in the overflow bin for room [ROOM NUMBER]A: Atorvastatin 1 bottle with expiration of 4-26-2023 and one bottle with expiration of 8-30-2023 Losartan 1 bottle with expiration of 6-21-2023 and one bottle with expiration of 8-30-2023 Gabapentin 1 bottle with expiration of 8-30-2023 During an interview on 9-12-2023 at 09:33 AM the DON and CRN they verified that the three prescription medication were expired, were part of the overflow stock, and that if the primary medication cart on the floor was out of medication, then the nurse would grab what they needed from this stock in the medication room. The DON reported that she did not feel the expired medication would be a problem because the staff are trained to check each medication for expiration prior to being administered. The DON stated, The chance an expired medication would be given would be slim. We check dates when we pass any meds. The CRN agreed. The DON reported that the expired medications were brought in when the resident in room [ROOM NUMBER]A was admitted recently and they expected him to be short term but he has since decided to stay and the medications he brought in were not discarded as they should have been. During an interview on 09-13-2023 at 08:52 AM LVN A reported that if a resident is out of a prescription medication in the medication cart, they will check the medication room for the overflow Page 1 of 4 675049 675049 09/13/2023 Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some section that is located on one wall and see if the resident has that medication that has been refilled. If the medication is available, they will check if for expiration and ensure that all other valid information is present such as resident name, dose, etc. then put the medication in use. During an observation on 09-12-2023 at 09:27 AM of Medication Cart 1, the three medications currently in use listed above for room [ROOM NUMBER]A had an expiration date listed in the year 2024. Record review of the facility provided policy titled Storage of Medications revised November 2020, revealed the following: Policy Interpretation and Implementation: 4.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 675049 Page 2 of 4 675049 09/13/2023 Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review the facility failed to provide training to their staff for abuse, neglect, and exploitation for 4 (SLP, CNA B, CNA C, and LVN D) of 13 employees evaluated for the required trainings. SLP was hired 7-11-2020 and no training had been provided on Abuse, Neglect, and Exploitation in the last 12 months. CNA B was hired 7-11-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. CNA C was hired 6-21-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. LVN D was hired 12-23-2022 and no training was provided on Abuse, Neglect, and Exploitation at hire. This failure could place residents at risk for harm from staff that have not been trained adequately to provide appropriate care and prevent injuries. This failure could result in deterioration in resident condition, injuries, and exacerbation of the disease process. Findings included: Record review completed 9-13-2023 at 02:01 PM of SLP's (Speech Language Pathologist) employee file revealed the following: SLP was hired 7-11-2020 and no training was provided on Abuse, Neglect, and Exploitation in the last 12 months. Record review completed 9-13-2023 at 10:47 AM of CNA B's employee file revealed the following: CNA B was hired on 7-11-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. Record review completed 9-13-2023 at 10:59 AM of CNA C's employee file revealed the following: CNA C was hired on 6-21-2023 and no training was provided on Abuse, Neglect, and Exploitation at hire. Record review completed 9-13-2023 at 11:08 AM of LVN D's employee file revealed the following: LVN D was hired on 12-23-2022 and no training was provided on Abuse, Neglect, and Exploitation at hire. During an interview on 9-13-2023 at 01:38 PM the BOM/HR (Business Office Manager/Human Resource Manager) reported that she had just been placed as head of the HR department and that she was aware that new employee orientation had not been completed correctly. The BOM/HR reported that she was scheduled for a training next week that should correct all current problems with employee training. The BOM/HR verified that the 4 employees were not trained upon hire and reported that the nursing department was responsible for ensuring that the trainings were completed when hired. The BOM/HR reported that if staff did not receive the required trainings then we could have staff that are not prepared to take care of residents. During an interview on 9-14-2023 at 10:12 AM the DON verified that she completed all required trainings related to nursing to include Abuse, Neglect, and Exploitation when an employee is hired. The 675049 Page 3 of 4 675049 09/13/2023 Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some DON reported that she felt that all employees listed above had completed the required training and that she just felt that their orientation form had been misplaced or was simply not filled out. The DON reported that if a staff member was not trained on what they need to know then they may not provide safe care. Record review of the facility provide policy titled, New Hire and Annual Training Packet revealed the following: Section-Abuse Prevention Program, revised 1-9-2023: 4, Our Center will implement and permanently maintain an effective training program for all staff . Policy Interpretation and Implementation2. Requires staff training/orientation programs . 675049 Page 4 of 4