Health inspection·December 7, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff on 1 of 4 halls (300 hall) reviewed for a safe and comfortable environment. The facility failed to ensure water temperatures on 1 of 4 halls were not above acceptable ranges. (Hall 300) This failure could place the residents at risk of exposure to uncomfortable or unsafe water temperatures. Findings included: During observations on 12/5/22 the following water temperatures were noted in resident hand sinks: Hall 300: -*at 10:22 a.m., the hand sink in room [ROOM NUMBER] hot water felt uncomfortable hot to the touch; and -*at 10:24 a.m., the hand sink in room [ROOM NUMBER] hot water felt uncomfortable hot to the touch. During an observation and interview on 12/5/22 at 10:26 a.m., the Maintenance Supervisor checked the water temperature in the hand sink in room [ROOM NUMBER] and the thermometer indicated the temperature was 114 degrees F. During an interview on 12/5/22 at 10:28 a.m., the Maintenance Supervisor said the water was too hot and said it could be a safety issue if the water got any hotter . He said he was to the keep the hot water in resident's bathrooms at 110 degrees F. or below and checked daily. During an interview on 12/5/22 at 10:35 a.m., the Administrator checked the water temperature at the hand sink in the bathroom of room [ROOM NUMBER] and said the water was 114 degrees and must be adjusted . During an interview on 12/6/22 at 10:00 a.m., the Administrator said they followed a computerized maintence record keeping system for their policy on the water temperatures and provided a copy. Page 1 of 6 675835 675835 12/07/2022 Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the water temperature log, dated 12/5/22, indicated Water was checked in room [ROOM NUMBER] : 86.1 degrees, room [ROOM NUMBER] : 89.2 degrees, room [ROOM NUMBER]: 97.2 degrees and room [ROOM NUMBER] :97.1 degrees . Record review of the facility's, undated, Tels Masters Policy indicated . Accidents-Water Temperatures . The facility must ensure that the resident environment remains free of accidents as is possible . 1. Ensure patient room water are between . Texas . 100 to 110 [degrees]. 675835 Page 2 of 6 675835 12/07/2022 Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who use psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 13 residents (Resident #8) reviewed for unnecessary medications. *The facility failed to monitor Resident #8 for behaviors for the antipsychotic medication Abilify (an antipsychotic medication used to treat certain mental/mood disorders) and Seroquel (an antipsychotic medication that works by changing the chemicals in the brain). This failure could place residents at risk for adverse consequences of psychotropic medications. Findings included: Record review of Resident #8's face sheet indicated Resident #8 was readmitted to the facility on [DATE] and, was a 66- years- old female with diagnoses which included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Resident #8's quarterly MDS assessment, dated 10/11/22, indicated Resident #8 had moderate cognition impairment with diagnoses which included bipolar disorder and schizoaffective disorder and received an antipsychotic medication 7 of 7 days during the look back period. Record review of a care plan, with a review date of 10/17/22, indicated Resident #8 received psychotropic medication of Abilify and Seroquel with interventions which included monitor and record occurrence of target behavior symptoms which included resistance to care, agitation and paranoid delusions . Record review of the Physician orders, dated December 2022, indicated Resident #8, was prescribed Abilify 1 mg at bedtime for schizoaffective disorder with a start dated of 10/05/2021 and Seroquel 300 mg at bedtime for schizoaffective disorder with a start date of 04/11/2022. Record Review of the MAR, dated December 2022, indicated Resident #8 received Abilify 1 mg every day at bedtime from 12/01/22 to 12/06/22 at 8:00 p.m. and Seroquel 300 mg every day at bedtime from 12/01/22 to 12/06/22 at 8:00 p.m., with no monitoring for behaviors for an antipsychotic medication noted. Record review of the electronic medical record for Resident #8 contained no documentation of monitoring for behaviors for Abilify or Seroquel from 12/1/22-12/7/22. During an interview on 12/07/22 at 12:23 p.m., RN A said she cared for Resident #8. RN A said the nurses were responsible for psychotropic medication monitoring for side effects, behaviors and documentation. She said the DON and ADON were responsible to double check that psychotropic medications were monitored. RN A said she monitored psychotropic medication for behaviors, and she was not sure why the behavior monitoring was not showing in Resident #8's EMR (electronic medical record). She said she received education on monitoring medications a couple of months ago. RN A said the risk was 675835 Page 3 of 6 675835 12/07/2022 Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785

F 0758 improper dosage of the psychotropic medication when behaviors were not monitored. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/07/22 at 12:37 p.m., the DON said her expectation was all residents who received psychotropic medications were monitored for side effects and behaviors. The DON said Resident #8's Abilify and Seroquel were not monitored for behaviors and should be monitored. She said it was just missed. The DON said the charge nurses were responsible for the monitoring and documentation of behaviors for psychotropic medications. The DON said she and the ADON were responsible for clarifying orders for accuracy and making sure all medications that required monitoring were monitored. The DON said the risk of not monitoring behaviors when receiving psychotropic medications included improper dosage of the psychotropic medication, medication adjustments not made, falls and weight loss. Residents Affected - Few She said the staff had recently received education on medication monitoring. During an interview on 12/07/22 at 01:45 p.m., the ADON said monitoring of psychotropic medication was a team effort starting with the charge nurses with herself and the DON responsible for follow up by reviewing the orders. The ADON said Resident #8's missed behavior monitoring was overlooked. She said the behavior documentation previously was on paper forms and when the change to EMR occurred it just fell through the cracks. She said the nurses were educated on monitoring and documentation of psychotropic medication within the last 6 months. The ADON said psychotropic medications not monitored for behaviors posed a risk of improper psychotropic medication dosage, either missed needed dosage increase due to behaviors or a missed needed GDR (Gradual dosage reduction). During an interview on 12/07/22 at 3:00 p.m., the Administrator said his expectation was for staff to monitor psychotropic medication according to protocol with all documentation completed as required. He said the administrative staff all sat in on meetings with the pharmacy consultant and Resident #8's behavior monitoring was overlooked. He said the risk of a psychotropic medication not monitored for behaviors could risk a missed needed increased dosage if not effective or missed decreased dosage as needed. Record review of the facility's, undated, policy titled, Antipsychotics indicated: . It is the policy of this facility to appropriately utilize and monitor the use of antipsychotics throughout the tenure of a residents stay. 6. Side-effect monitoring in place 7. Behavior monitoring in place . b. Follow-up as indicated (special focus on Gradual Dose Reduction- GDR). 675835 Page 4 of 6 675835 12/07/2022 Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 nurse medication carts (Hall 400 nurse medication cart) reviewed for drug storage. The facility failed to ensure nurse medication cart on Hall 400 was locked and supervised. This failure could place residents at risk for possible drug diversion. The findings include: During observation and interview on 12/05/22 at 9:07 a.m. to 9:09 a.m. revealed an unlocked medication cart for Hall 400 that was left unsupervised and parked in the unlocked open area nurses' station that was also the activity/dining room area. The drawers of the medication cart were not facing the wall and anyone who walked by in the nurses' station could have opened them. No staff members were in the direct line of sight to medication cart, LVN B was approximately 25 to 30 feet away from the cart with her back turned towards the medication cart and was administering medications to a male resident. There was a CNA staff member in the nurse's station area playing cards and puzzle pieces with two unidentified female residents who sat in their wheelchair. At 9:09 a.m. the state surveyor notified LVN B, who was in charge of the cart, LVN B turned around and came to the cart and said she was sorry for leaving the cart open and she was the person responsible for administering medications on the 400 hall and used the cart. LVN B stated with her back turned to the cart, the cart was out of her line of site. LVN B said she was approximately 25 to 30 feet away from the cart administering another resident's medications and forgot to lock the cart before she stepped away from it. LVN B said the cart should not be unlocked and unattended because anyone walking by could get into the medications and risk medication theft or diversion. LVN B said she had been in-serviced this year to keep the medication cart locked at all times. During observation and interview on 12/05/22 at 9:07 a.m. to 9:09 a.m., inside the medication cart Drawer #1 revealed: Accu-check strips and glucometers, OTC (Over the counter) aspirin, vitamins, minerals and eye drops. Drawer #2: Locked compartment with controlled substance, and multiple resident's individual medication bubble-blister packets. During an interview on 12/07/22 at 1:30 p.m., the DON said she expected the nurses to follow the facility values, policy and procedure when it came to med pass and drug safety. She said the medication carts should be locked if staff walked away from it or turned their back to it. The DON stated she was responsible for making sure the nurses locked the carts because of risk for misappropriation of property. The DON said she made random rounds daily and checked to make sure nurses were locking their medication carts. She said she had in-serviced nursing staff to keep the medication cart locked at all times. She stated nurses were trained during orientation, annually and as the needed, on medication administration and securing meds. Record review of the facility's, undated, policy and procedure titled, Securing Medication and Treatment Carts indicated the following: Procedure: It is expected that medication carts and treatment carts are to remain locked at all times when not in use by the assigned personnel 675835 Page 5 of 6 675835 12/07/2022 Cherokee Trails Nursing Home 330 E Bagley Rd Rusk, TX 75785

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to maintain all mechanical, and electrical, and patient care equipment in safe operating condition for 1 of 1 kitchentwo of six burners reviewed in the kitchen for safe operating equipment. Residents Affected - Few The facility failed to ensure two of the six burners on the gas stove in the kitchen lit when turned on. This failure could place residents at risk of breathing in gas fumes and food borne illness. Findings included: During an observation on 12/5/22 at 8:45 a.m., the Assistant Dietary Manager turned on the stove burners and 2 of the 6 burners (right and left side back burners) did not lite with turning the burner on. During an interview on 12/05/22 at 12:35 p.m., the Assistant Dietary Manager said if the burners did not light with the pilot light, it could allow gas to escape or if another burner was lit it could cause a puff of gas fumes to light and could cause problems with safety. During an interview on 12/6/22 at 03:57 p.m., the Dietary Manager said the stove should work properly and if not tell maintenance. She said the burners were working properly on 12/02/22. During an interview on 12/7/22 at 9:38 a.m., the Assistant Maintenance Staff said that he was told about the stove not lighting with the pilot light after the state surveyors entered the facility, and he lit the pilots. 675835 Page 6 of 6