Health inspection·March 3, 2023

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 6 residents (Resident #307), reviewed for the Drug Regimen Review (DRR). The facility failed to review and act on, Resident #307's allergy to sertraline, reported by the pharmacist as a high priority on the DRR report, dated 2/24/23. This failure could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and could place them at risk for adverse consequences related to medication therapy. The findings included: Record review of resident #307's face sheet, printed 3/3/23, revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of fracture of left femur (fracture of the left thigh bone), wedge compression fracture of unspecified thoracic vertebra (fracture of the vertebra in the spine that is in the chest area, that causes a wedge shape), nontraumatic intracerebral hemorrhage (bleeding in the brain, not caused by injury), pleural effusion (fluid between the tissues that line the lungs and the chest cavity), dysphagia (trouble swallowing), muscle weakness, muscle wasting and atrophy (muscles become smaller from nonuse), hypertension (high blood pressure), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out simple tasks), repeated falls, and acute kidney failure (sudden/short onset of kidneys not working properly). Per original face sheet, seen on 3/2/23, sertraline was one of the allergies listed. Once the Surveyor brought the allergy concern to the facility's attention at the end of the day on 3/2/23, the facility removed the allergy listed on the face sheet. Record review of resident #307's initial MDS dated [DATE], revealed a BIMS score of 5 out of 15, indicating severe impairment with cognition. Also, on question N2001 of the MDS it asked, Did a complete drug regimen review identify potential clinically significant medication issues? The answer was marked as No No issues found during review. Record review of resident #307's Care Plan dated 2/22/23 revealed Ms is at risk for allergic reaction r/t allergies to the following: .sertraline . Ms .will have no allergic reactions through the next review date: Monitor for signs and symptoms of possible allergic reactions such as: hives, rash, swelling, watery eyes, wheezing and report finding to MD as indicated. Notify MD if patient has an allergic reaction to new medications or food for further instructions. Provide MD and other medical professionals a list of allergies when reviewing medications. Review list of allergies prior to Page 1 of 6 675819 675819 03/03/2023 Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administration of medications. The Care Plan also revealed the resident has withdrawn and uses antidepressant medication. At risk for side effects. She will be free from discomfort or adverse reactions related to antidepressant therapy through the review date: Behavior monitoring for withdrawn medication; sertraline document # of behaviors exhibited during the shift. Give antidepressant medication ordered by physician. Report to nurse s/sx of following: mood change, change in normal behavior, hallucinations/delusions, suicidal ideations, withdrawal, constipation, decline in function/adls. Also revealed in Care Plan, Ms .has impaired cognitive function/impaired thought processes r/t Alzheimer's. She will improve decision making ability by next review date: Administer meds as ordered. Observe/document/report to MD any changes in cognitive function, specifically changes in: .Review medications and observe possible causes of cognitive deficit: new medications or dosage increases .drug interactions, errors or adverse drug reactions, drug toxicity. Record review of resident #307's history and physical received from the hospital, with date of visit 2/12/23, revealed sertraline was one of the resident's allergies. Record review of resident #307's facility admission note dated 2/21/23, listed sertraline was one of her allergies. Record review of resident #307's physician orders revealed an order with a start date of 2/22/23, for Sertraline HCL 50mg tablet, Give 1 PO QD for depression. Resident #307 also had a physician's order with a start date of 2/22/23 for monitoring side effects of antidepressant medication every shift, and to chart all appropriate codes: 0=none, 1=sedation/drowsiness, 2=increased falls/dizziness, 3=hypotension (low blood pressure), 4=anxiety/agitation, 5=blurred vision, 6=sweating/rashes, 7=weakness, 8=headache, 9=dystonia (involuntary muscle contraction), 10=urinary retention/hesitancy, 11=anticholinergic symptoms (dry mouth, constipation, bowel obstruction, dilated pupils, decreased sweating), 12=cardiac abnormalities, 13=tremors, 14=appetite chg/wt chg, 15=insomnia, 16=confusion, 17=tardive dyskinesia (uncontrollable, repetitive movements of the face, torso, and other parts of the body), 18=suicidal ideation every shift. Record review of facility's DRR revealed a report dated 2/24/23 from the pharmacist, marked high priority that stated, Resident #307 has an allergy listed to sertraline and is receiving sertraline. Please review. The report was reviewed and signed by the DON, but undated. Record review of resident #307's MAR for February 2023 revealed she received Sertraline HCL 50mg 1 PO QD for depression, on 2/21/23 through 2/28/23 at 6:00am. Record review of resident #307's MAR for March 2023 revealed she received Sertraline HCL 50mg 1 PO QD for depression, on 3/1/23, 3/2/23, and 3/3/23 at 6:00am. There were no records of any documentation in resident #307's chart that stated the sertraline allergy was reviewed by the facility or Medical Doctor, or if it was okay to continue the medication. There also were no records of documentation in the chart between the facility and the family regarding the allergy before the Surveyor notified the facility about the concern on 3/2/23. An interview with the NP on 3/2/23 at 4:30pm revealed resident #307 had sertraline listed as an allergy in her chart in the EMR, however the NP was not sure what the allergy was to the medication. The NP also confirmed the resident was taking sertraline even though it was listed as an allergy in her chart. The Surveyor showed the NP the DRR report dated 2/24/23, with the DON's signature on it. Per the NP she had no knowledge of the DRR and was never told about it. Also, per the NP, the facility 675819 Page 2 of 6 675819 03/03/2023 Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff should have contacted her or the doctor, through phone, fax, or the communication book, and she was not aware of any contact. The NP said confusion was a symptom of an allergic reaction, and garbled/incoherent speech could be a component of that. The NP said the reason the resident was taking sertraline, even though it was listed as an allergy, was because she was taking it at the hospital and the facility continued it when she got to the facility. Per the NP, the facility restarted the sertraline the resident was taking at the hospital, and because the hospital was giving it, the resident most likely did not have a true allergic reaction. The NP said it could have been that the resident did not like one of the side effects, or something that was normal for the medication, and if there was not a true allergy listed or identified, they continued the medication. Per the NP, this was just a theory, as she was not sure if this is what happened. However, the NP stated the facility should have notified her of the discrepancy right away. An interview with the DON on 3/3/23 at 12:00pm revealed that if there was a change in the resident's status, the facility reported it to the attending provider or to the Medical Director. Per the DON the Medical Director's office was right across the street from the facility, so he was at the facility all the time. Also, the DON stated the facility had the Director's cell phone number, and the doctors at the facility were attentive and easy to communicate with. Per the DON, to ensure orders for medication monitoring were implemented, there were 2-3 different people that checked the orders. The DON stated the admitting nurse first put the orders in, the DON checked the orders second, the MDS nurse checked them, and finally the ADON checked the orders. So, per the DON, orders went through several checks for mistakes. The DON stated the staff performed walking rounds and even the managers would make rounds, to assess for significant adverse consequences to the residents. She stated the staff also gave good end of shift reports, and the nurses sent residents to the hospital if they felt like they did not improve and required interventions they did not need before. The DON also stated assessments (like if the resident had a reaction or side effect) were important, and performed often, to decide if medication needed to be initiated, continued, reduced, discontinued, or otherwise modified. Per the DON the facility evaluated residents all the time, to see if modification of medication was necessary, and it was a group effort. She stated anyone in the facility, could and would, speak up and say something if they noticed the resident acted different. When asked about the DRR process, the DON stated the physicians did not review it right away, and it could take a few days or be something the facility investigated. When the DRR report with the DON's signature on it, was shown to her, the DON stated the facility started giving sertraline to resident #307 because the resident received the medication at the hospital. The DON stated she spoke to the family, and they confirmed the resident was not allergic to sertraline. The Surveyor explained to the DON that there was no documentation in Resident #307's chart indicating any communication with family, nor was there any documentation in the chart that the MD had reviewed the DRR report of the allergy. The DON stated the allergy was addressed and confirmed, and that she had spoken to the physician about it, because her signature was at the bottom of the DRR. However, per the DON, I guess there's no documentation from the doctor saying that he knew about it and that it was ok. The DON stated the risk of taking the medication if she was allergic to it, would be an allergic reaction, and an allergic reaction could cause grogginess or sleepiness. Record review of the facility's Medication Regimen Reviews policy (revised April 2007) read in part: The Consultant Pharmacist shall review the medication regimen of each resident at least monthly. Policy Interpretation and Implementation: 1. The Consultant Pharmacist will perform a medication regimen review for every resident in the facility . 5. The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications 675819 Page 3 of 6 675819 03/03/2023 Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089

F 0756 Level of Harm - Minimal harm or potential for actual harm appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. 6. As part of the MRR, the Consultant Pharmacist will: a. Evaluate whether any medication in a drug regimen present potentially significant drug-drug or drug-food interactions; Residents Affected - Few b. Determine if the resident is receiving the correct medications as ordered; . e. Be alert to medications with potentially significant medication-related adverse consequences and to actual signs and symptoms that could represent adverse consequences; and f. Identify medication errors, including those related to documentation. 7. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report. 8. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the Physician directly to report the information to the Physician, and will document such contacts. If the Physician does not provide pertinent response, or the Consultant Pharmacist identifies that no action has been taken, he/she will then contact the Medical Director, or-if the Medical Director is the Physician of Record-the Administrator . 10. Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record. Record review of the facility's Charting and Documentation policy (revised July 2017) read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: .2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; . d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Record review of the facility's Administering Medications policy (revised March 2011) read in part: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: .2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions . 4. 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 shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns . 7. The following information must 675819 Page 4 of 6 675819 03/03/2023 Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089

F 0756 be checked/verified for each resident prior to administering medications: Level of Harm - Minimal harm or potential for actual harm a. Allergies to medications; . Residents Affected - Few 675819 Page 5 of 6 675819 03/03/2023 Park Manor of South Belt 11902 Resource Pkwy Houston, TX 77089

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed for kitchen sanitation Residents Affected - Some --the facility stored expired food items in the dry goods storage area This failure placed residents at risk of complications from foodborne illness and compromised health status. Findings include: Observation of the dry goods storage area on 3/1/23 at 9:05 am revealed (10) 12-ounce cans of evaporated milk on a shelf with expiration date of 1/14/23. The Dietary Manager said the cans of evaporated milk should not be on the shelf since they were past the expiration date. She said the cans were received in November, and it was an oversight that they were still on the shelf and took the cans off the shelf and put them in the trash. She said the staff member who took the deliveries would check the expiration dates. The Dietary Manager said the risk of someone ingesting expired milk could be death. In an interview on 3/3/23 at 12:20 pm, the DON said the cans of evaporated milk should not be on the shelf since they were expired. She said risk of someone ingesting expired milk could be gastrointestinal (stomach) issues. Record review of the facility policy Food Storage: Dry Goods, revised 9/2017, revealed: all dry goods will be appropriately stored in accordance with the FDA Food Code 675819 Page 6 of 6