Health inspection·April 6, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure residents were free of significant medication errors for 1 of 11 residents (Resident #1) reviewed for significant medication errors. Residents Affected - Few The facility staff failed to continue Resident #1's anticoagulant (Anticoagulants are a group of medications that decrease your blood's ability to clot) medication when she returned from the hospital after being gone less than 24 hours. The Resident missed 9 days of her anticoagulant medication which required treatment in a hospital for bilateral embolism (A pulmonary embolism is a clot in the veins of one or both lungs.) The noncompliance was identified as PNC(past non compliance). The IJ (immediate Jeopardy) began on 12/1/2022 and ended on 12/09/2022. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of serious harm or death due to not receiving physician ordered medication. Findings include: Record review of Resident #1's face sheet, dated 4/5/23, revealed an initial admission date of 10/17/2022 and re-admission date of 12/12/2022. Resident #1 had diagnoses which included: Alzheimer's disease (Alzheimer's disease is a brain disorder that slowly erodes memory, thinking, and behavior), Acute Embolism and thrombosis of unspecified deep veins of left lower extremity (Acute embolism and thrombosis of unspecified deep veins of lower extremity. If the vein swells, the condition is called thrombophlebitis. A deep vein thrombosis can break loose and cause a serious problem in the lung), personal history of pulmonary embolism and paranoid schizophrenia (Schizophrenia is a mental disorder that affects how a person thinks, feels, and behaves.) Record review of Resident #1's Quarterly MDS assessment, dated 2/27/2023, revealed a BIMS score of 2, which indicated cognitively impaired cognition. Section N - medications indicated anticoagulant received. Record review of Resident #1's Care plan, with date initiated as 12/12/2022, and revision date of 3/1/2023, revealed a focus of: at risk for abnormal bleeding/bruising related to the use of anticoagulant medication. History: Bilateral popliteal vein thrombosis (A blood clot in your circulatory system) and bilateral pulmonary emboli's. Interventions: Administer anticoagulant medications as ordered by physician. Observe for side effects and effectiveness. This was initiated on 10/17/2022 and a revision on 11/15/2022 and 12/18/2022. Page 1 of 5 675110 675110 04/06/2023 Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's physician orders, dated 10/18/2022, revealed medication Apixaban (blood thinner, anticoagulant) tablet 5.0 mg give 1 tablet by mouth two times a day. Record review of Resident #1's electronic medication administration record, for 12/1-12/31/2022, revealed medication Apixaban 5.0 mg give 1 tablet by mouth two times a day was not given beginning 12/1/2022 through 12/9/22, when Resident #1 went to the hospital. Residents Affected - Few Record review of Resident #1's hospital medical records for 12/9/2022-12/12/2022, provided by facility revealed an admitting diagnosis of bilateral pulmonary embolism . Record review of Resident #1's nursing notes dated 12/9/2022 revealed Resident #1 had an elevated temperature of 103.3, oxygen saturation of 88%,and labored breathing. She was sent to the hospital on [DATE]. During an interview on 4/6/2023 at 9:16 a.m. with LVN B revealed he was not working in facility on the date of 12/9/2022, when Resident #1 needed to be sent to the hospital. He stated he had in services regarding admission orders and anticoagulant medications and their side effects. He further revealed he was aware of Resident #1 having physician prescribed anticoagulant medication and knew side effects such as bleeding could occur. He stated he also was aware that if an anticoagulant was not taken as ordered blood clots could occur or a pulmonary embolus may occur. During a telephone interview with LVN A on 4/6/2023 at 10:25 a.m., he stated he was the nurse on duty when Resident #1 came back from the hospital on [DATE]. He stated orders were to resume previous medications. He stated there was no medication list provided. He further revealed Resident #1 had been discharged in the facility Electronic Medical Record system therefore he did not notice her past medications. He stated he was terminated from the facility because of what happened to Resident #1. He revealed no further information. During an interview on 4/5/2023 at 3:30 p.m., the facility DON revealed LVN A admitted Resident #1 on 11/30/22 back from an almost 24-hour emergency room visit for a chronic dislocated hip requiring treatment and then she was returned to the facility. She further revealed she was present on 12/9/22 when Resident #1 was sent to the hospital for a change in condition of feeling weak and not being like herself, which was alert, able to walk and to feed herself. DON further revealed on 12/10/2022 the spouse of Resident #1 came to facility and asked the DON if the resident had been getting her anticoagulant medication because she was diagnosed at the hospital with Bilateral Pulmonary Embolism. The DON started an investigation that day and then found the medication had not been given. The DON further revealed Resident #1's primary physician was notified on 12/9/2022 of Resident #1 not receiving her anticoagulant medication. During an interview on 4/6/2023 at 11:46 a.m., the facility DON revealed LVN A did not reach out for assistance or question the medical record for Resident #1. She further stated because the resident had been discharged before the full 24 hours, which was typically what the facility did, the error occurred. The DON stated the facility had all staff in services, and clip board in services (the DON goes around and individually speaks with staff.), 24 report summary, stand up and stand down meetings which the nurses came in and our IDT discussed the days occurrences. The DON revealed, she monitored staff through observations of practices while on duty, the ADON also did rounding checks. She stated the ADON'S did rounds and made sure medications were given to residents. They checked medication carts weekly for expired medications and to see if the medications the residents had ordered were correct. The DON stated they ensured residents were safe and free from harm through frequent 675110 Page 2 of 5 675110 04/06/2023 Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ambassadors checking on residents and what the facility called a stop and watch which when an aide was alerted to something they filled out a form, gave it to the nurse of duty, and they would follow up with the care needed. The DON stated the potential consequences of Resident #1 not getting her anticoagulant as physician ordered was she could have had prolonged illness or died. When asked if the return of Resident #1 on 11/30/22 was discussed at the next morning meeting and reviewed for medications the DON stated, no because Resident #1 technically wasn't admitted to the hospital. She (Resident#1) went to the local ER and then went to another hospital ER, was not admitted and then came back to the facility . She (Resident #1) never should have been discharged at the facility because she wasn't gone a full 24 hours. The DON stated, the nurse(LVN A) just jumped the gun, and discharged her(Resident #1) in the system at the facility which made the medication list not available. During an interview on 4/6/2023 at 11:58 a.m., the facility Administrator stated she did not know why the deficient practice occurred and she was not the Administrator at that time. The Administrator stated she monitored staff by having morning and evening meetings where the nurses came in and told the department heads if there were any changes or concerns with residents each business day. This was attended by all department heads. The Administrator stated she did rounds throughout the facility and checked on residents and staff. During an interview on 4/6/2023 at 11:30 a.m. the DON and Regional Nurse Consultant reported medication order reviews and MAR to cart audits were completed 12/10/2022- 12/14/2022. Staff were educated on abuse and neglect. All nurses were educated on medication reconciliation, order entry, notification of physician for clarifying medication, discharge process and when and what type of discharge was needed when a resident left the facility, education on drug regimen review and notifying MD of any issues. All orders for admissions were verified by two nurses for accuracy 12/10/2022-12/14/2022. The DON and 1 designee reviewed resident orders on admission, readmission, and transfers during the morning clinical meeting to ensure orders were transcribed correctly and results of findings discussed in the monthly QAPI meeting. The DON stated LVN A was terminated on 12/13/22 due to Resident #1 incident. During an interview on 4/6/2023 at 11:30 a.m. the Administrator, DON, and Regional Nurse Consultant stated all staff had been educated, and monitoring continues. The DON reported there were no further issues with the residents receiving their anticoagulants. Record review risk management documents, 24 hr report daily revealed the facility had a Medical Director meeting each month. Record review of the facility's investigation, with a start date of 12/10/22, confirmed Resident #1 had not received her ordered anticoagulant medication from 11/29/22 until discharged to hospital on [DATE]. The investigation determined the charge nurse LVN A had not transcribed the physician orders when she returned from the ER on [DATE]. Record review of a statement, dated 12/10/22 by LVN A, revealed when resident came back from the hospital, they said to resume previous medications. No medication list was provided. I went through her discontinue meds and restarted the meds she had been on. Record review of intakes revealed the facility made a report to the State Survey Agency regarding the incident on 12/10/22. Record review of actions taken by the facility revealed on 12/10/22 a QAPI meeting was held with 675110 Page 3 of 5 675110 04/06/2023 Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the former Administrator, Medical Director, DON, and Regional Nurse Consultant and a performance improvement plan was developed with immediate interventions, re-education, systemic changes, and monitoring outcomes. Record review of actions taken by the facility revealed on 12/10/22 and 12/11/22 all residents in the facility who received anticoagulants were reviewed for order accuracy, medication administration, and lab work if required and a binder was started. Record review of actions taken by the facility revealed on 12/10/22 all admissions, readmissions, and transferred residents for the last 30 days was started to ensure accuracy of orders and was completed by the DON, ADON, and Regional Nurse Consultant on 12/11/22. Record review of actions taken by the facility revealed on 12/10/22 a MAR to the medication cart review was started for all residents and completed by the DON, ADON, and Regional Nurse Consultant on 12/11/22. Record review of actions taken by the facility revealed on 12/10/22 an In-service training signed by the DON, ADON's, and Regional Nurse Consultant for review of all admissions within 24 business hours was to be completed for accuracy of physician orders, completion of required assessments and forms, verifying all medications were received from pharmacy, and care plans were in place with interventions and an admission/readmission checklist placed in charts. Record review of actions taken by the facility revealed on 12/10/22 and 12/11/22 all nurses were educated on the discharge and admission process with details the resident was not to be discharged from the facility until they had been out of the facility for 24 hours and upon admission, readmission, and return from the emergency room the admitting nurse would verify all medication with the physician and if the medication list was not sent with the discharge paperwork received by the facility, then the most recent medication list would be sent to the provider for review and confirmation. If the drug regimen review identified any issues the physician must be notified. The transfer/discharge form, and drug regimen review were also reviewed separately with the nurses on 12/11/22. Record review of actions taken by the facility revealed on 12/10/22 the DON, ADON's, and RN supervisor were educated that orders were to be reviewed daily for all new orders from admission, readmission, procedures, and ER visits with details on how to pull the order listing from the computer and looking for written orders at the nurses' station to verify and scan. Record review of actions taken by the facility revealed on 12/10/22 and 12/11/22 CMA's, LVN's, and RN's were educated on medication order management for understanding the process of entering medication orders into PCC (Point Click Care-Computer system) and how to review, clarify new and existing medication orders with physician medication reconciliation and sending the list for the physician to review. Record review of actions taken by the facility revealed on 12/10/22, 12/11/22, 12/12/22, 12/14/22, and completed on 12/16/22 all facility staff (housekeeping, dietary, therapy, nursing, CMA, and CNA's) were educated on abuse and neglect, how to report, and where the number was posted for reporting. Record review of the facility's, undated, Abuse Prevention, Identification and Reporting policy, revealed: Neglect is a pattern of conduct or inaction of a care provider that fails to provide goods or services that maintain physical or mental health or that fails to avoid or prevent physical or 675110 Page 4 of 5 675110 04/06/2023 Cuero Nursing and Rehabilitation Center 1310 E Broadway Cuero, TX 77954

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few mental harm or pain, or an act of omission that constitutes a clear and present danger to health, welfare or safety of a resident. Record review of the facility medication reconciliation policy, date implemented 10/24/22, revealed . refers to the process of verifying that the resident's current medication list matches the physician's orders for the purposes of providing the correct medication to the resident at all points throughout his or her stay. 4. admission Processes: b. compare orders to hospital records, etc. Obtain clarification orders as needed. C. Transcribe orders in accordance with procedures for admission orders. d. Have a second nurse review transcribed orders for accuracy and cosign the orders, indicating the review This was determined to be Past Noncompliance Immediate Jeopardy (PCN IJ) on 4/6/2023 at 4:30 p.m. The Administrator was notified The Administrator was provided with the IJ template 04/06/2023 at 4:30 p.m. The facility had corrected the noncompliance before the survey began. 675110 Page 5 of 5