Health inspection·May 19, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 29 residents (Residents #9 and #101) reviewed for advanced directives. Residents #9 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. Residents #101 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. This failure could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #9 Record review of Resident #9's face sheet, dated [DATE], revealed an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Parkinson's (a progressive nervous system disease), dementia (progressive loss of intellectual functioning), atrial fibrillation (irregular or rapid heartbeat that causes poor blood flow),major depressive disorder and Alzheimer's (progressive disease that destroys memory and other mental functions) Record review of Resident #9's face sheet, dated [DATE], revealed Advance Directive DNR Record review of Resident #09's physician order summary dated [DATE] revealed a DNR order dated [DATE] related to code status or advanced directive. Record review of Resident #09's care plan, dated [DATE], revealed a care plan for DNR Status: Focus: I/Family/RP has completed documentation for DNR status. I wish to be designated as DNR Goal: Community will follow DNR status request. Interventions: A physician's order for DNR is to be placed in my clinical record, Keep a copy of Page 1 of 19 675874 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the OOHDNR form in my clinical record, Send a copy of the OOHDNR with me in the event of transfer to the hospital or other facility Record review of Resident #09's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Section B the medical power of attorney had not checked any of the check boxes that indicated why they were acting on the behalf of Resident #09. Section 3 was missing a date to indicate when the signatures were obtained. Resident #101 Record review of Resident #101's face sheet, dated [DATE] revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include dementia (progressive loss of intellectual functioning), Atherosclerotic heart disease (buildup of fats and cholesterol plaque in the walls of the arteries) and anxiety disorder. Record review of Resident #101's physician order summary dated [DATE] revealed an order for Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #101's care plan, dated [DATE], revealed care plan for Advance Care Plan: Focus: Resident/Family/RP does not have advance directives and elects Full Code Status. designating that the resident is a FULL CODE (CPR) status Goal: Community will follow full code status through review date Intervention: Initiate CPR if I am without a pulse Review code status at least annually and as indicated. The care plan did not indicate a DNR status update. Record review of Resident #101's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the Physician's Statement revealed there was no date. Further review revealed at the bottom of the form indicated All persons who have sign, acknowledging that this document has been properly completed. revealed there was no signature from either of the two witnesses and no signature from the notary. An interview was conducted on [DATE] at 11:06 AM, the ADON said she had been at the facility for two months. She said she had been an RN for 20 years. She said resident DNR forms were everyone's responsibility and it was a team effort. She said the resident and the family work with the social worker, and the social worker was the one who completed the paperwork done. As the nurse, they would educate the family and the resident on what DNR meant. She said the form should be completed for the request to be valid. She said the signatures and the dates on the form indicated when the DNR became valid. She said the DNR would only be valid if all signatures were included. She said if the DNR form was invalid, then is the resident was considered a full code, and chest compression would be performed. She said if a resident wished to be a DNR and CPR was performed, then the facility would have been going against their wishes. She stated she was responsible for the C-wing in the facility and not the memory care unit. She stated the pharmacy nurse and DON typically cover the memory unit. She reviewed Resident #9's DNR and acknowledged that Section B was missing information and the date was missing at the bottom. She acknowledged that Resident #101's DNR was missing signatures at the bottom of the witness and the notary. She said she had not been trained specifically at the facility 675874 Page 2 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few regarding DNRs but was handed a list of DNRs for her section in the facility. She said the potential negative outcome was the staff could perform CPR, and the caregiver could say it was not legit and become upset. She said she expected all appropriate and applicable places should be completed on the DNR form so that it was valid. She stated the doctor's signature and date were the most important. She said she was unsure why the middle of the form was not completed, why the bottom was not dated for Resident #9, and why Resident #101 was not completed. An interview was conducted on [DATE] at 11:43 AM, the Social Worker (SW) said that she was responsible for completing the resident DNRs. She said another social worker at another facility would assist her and review her work since she was working under that worker's license. She said when a resident wishes to be DNR status, she has the nurse talk to the resident and their family so that they fully understand what they are requesting. Then, if they wanted to proceed, she would find someone not in the line of care to witness. She said after obtaining the doctor's signature and all appropriate signatures, she would make a copy and provide the DON with a copy. Lastly, she would upload the final copy into the resident's electronic file. She said the copy uploaded in the electronic file should be the final form. She said she expected all appropriate and applicable fields to be completed. She said if the relevant and appropriate fields were missing, the DNR was not valid. She said if the DNR is not valid, this would mean that the resident would be a full code. She said this could potentially go against the resident's wishes. She said that she had been trained on the completion of DNRs. She said she was unaware that Residents #9 and #101 had incomplete DNRs. She said that she audits the DNRs every couple of months. An interview was conducted on [DATE] at 11:55 AM, the Pharmacy nurse said DNRs are usually taken care of by the SW. She said that the SW usually had one of the nurses look at the DNR when it comes from the physician. She said she was unaware of any issues. She said she had been trained on the facility's process for DNRs. She said she expected DNRs to be fully completed before scanning into the chart and that they should be updated throughout the chart to reflect the resident's status. She said if the DNR was not fully completed, then the DNR was not valid. She said the potential negative outcome would be that the resident's wishes would not be upheld. An interview was conducted on [DATE] at 12:52 PM, the ADM said that she would have to check specifically for her facility but that, in her experience, social services were responsible. She said she had been trained on the completion DNRs and was unaware that some residents had incomplete DNRs. She said she expected the DNR to be complete and all appropriate and applicable areas on the form completed. She said the potential negative outcome would be the wishes of the veterans may not be fulfilled. However, she said if the form was in the electronic medical record, she understood it was complete and ready. Record review of the facility's policy, Advance Directives, Revised February 2017, revealed the following documentation: Compliance Guidelines A copy of the advance directive and subsequent revisions will be included in the resident's medical record. Advance Directive Modifications The resident has the right to modify the advance directive at any time. Although the resident 675874 Page 3 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0578 should advise the community whenever a change is made, it is the community's responsibility to ensure that it has current copies of all advance directives. Level of Harm - Minimal harm or potential for actual harm The community will survey its residents at least annually regarding any advance directives changes. Residents Affected - Few Record Review of the Instructions For Issuing An OOH-DNR Order (Undated) revealed the following: INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C . Section F - If an adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, proxy, or available qualified relative to act on his/her behalf, then the attending physician may execute the OOH-DNR Order by signing and dating it in In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. 675874 Page 4 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 6 residents (Residents #7, 59, 36, 62, and 96) reviewed for PASRR screening, in that: Resident #7 did not have an accurate PASRR Level 1 assessment when he had a diagnosis of major depressive disorder. Residents #59 and #62 did not have accurate PASRR Level 1 assessment when they had a diagnosis of post-traumatic stress disorder (PTSD) and Major Depressive Disorder. Residents #36, #62, and #96 did not have accurate PASRR Level 1 assessment when they had a diagnosis of post-traumatic stress disorder (PTSD). These failures could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs. The findings were: Resident #7: Record review of Resident #7's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, major depressive disorder (MDD). Record review of Resident #7's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 8 indicating the resident was mildly cognitively impaired. Record review of Resident #7's most recent care plan, undated, revealed a focus area and diagnosis of Major Depressive Disorder. Record review of Physician progress notes for Resident #7 dated 05/19/2023 revealed under current medications, documentation indicated the resident was prescribed Paroxetine (antidepressant) 10mg once daily. Record review of Resident #7's Preadmission Screening and Resident Review Level One (PL1) form dated 03/24/2021 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #59: Record review of Resident #59's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnoses of Chronic Post-Traumatic Stress Disorder (PTSD) and Recurrent and Severe Major Depressive Disorder. 675874 Page 5 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #59's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of depression and post-traumatic stress disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 15 indicating the resident was mildly cognitively impaired. Record review of Resident #59's most recent care plan, undated, revealed a focus area with problem onset date of 11/17/2021 which read in part that Resident #59 is at high risk for side effects due to a diagnoses of Post-Traumatic Stress Disorder and Major Depressive Disorder. Appropriate interventions are in place to assist with the behaviors associated with Major Depressive Disorder and Post Traumatic Stress Disorder. Record review of Physician progress notes for Resident #59 dated 05/19/2023 revealed under Current Diagnosis, diagnoses including PTSD and MDD. Resident #59 is not currently prescribed medications for depression, trauma, and anxiety. Record review of Resident #59's Preadmission Screening and Resident Review Level One (PL1) form dated 10/29/2021 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #36: Record review of Resident #36's electronic face sheet dated 5/24/23 revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis indicated diagnoses of post-traumatic stress disorder (PTSD), Intermittent Explosive Disorder, Anxiety Disorder, Cognitive Communication Deficit. Record review of Resident #36's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses of dementia, anxiety disorder, and post-traumatic stress disorder (PTSD). Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 14 indicating the resident was mildly cognitively impaired. Record review of Resident #36's most recent care plan, undated, revealed a focus area with problem onset date of 11/14/2022 which read in part that Resident #36 is at high risk for side effects due to a diagnosis of Post-Traumatic Stress Disorder. Appropriate interventions are in place to assist with the behaviors associated with Post Traumatic Stress Disorder. Record review of Physician progress notes for Resident #36 dated 05/19/2023 revealed under Current Diagnosis, a diagnoses including post-traumatic stress disorder (PTSD), Intermittent Explosive Disorder, Anxiety Disorder, Cognitive Communication Deficit. Resident #36 was currently prescribed Buspirone 10MG three times a day for anxiety and Thiamine 100MG a day for Dementia. Record review of Resident #36's Preadmission Screening and Resident Review Level One (PL1) form dated 08/20/2020 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #62 Review of Resident #62's face sheet revealed an [AGE] year-old-female with an admission date of 02/19/2021 with a primary diagnoses of Post Traumatic Stress Disorder, Major Depressive Disorder, and 675874 Page 6 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0644 Anxiety Disorder, and Insomnia. Level of Harm - Minimal harm or potential for actual harm Record of Resident #62 physician orders dated 05/19/23 revealed Sertraline HCL 100mg tablet give 1.5 tabs (=75mg) by mouth daily for depression dated 01/27/21. Residents Affected - Few Record review of Resident #62's most recent care plan, undated, revealed a focus area of Resident #62 was at high risk for side effects due to a diagnoses of Post-Traumatic Stress Disorder, anxiety, and Major Depressive Disorder. Appropriate interventions are in place to assist with the behaviors associated with Post Traumatic Stress Disorder. Review of Resident #62's PASRR assessment Level 1 Screening dated 10/26/21, under Section C0100 revealed documentation indicating Resident #62 did not have a mental illness. Review of Resident #62's Annual MDS assessment dated [DATE], revealed under section I Active Diagnoses of anxiety disorder, depression, and post-traumatic stress disorder (PTSD). Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 15 indicating the resident was mildly cognitively impaired. Resident #96 Review of Resident #96's face sheet revealed a [AGE] year-old-female with an admission date of 10/13/22 with a primary diagnosis of Post-Traumatic- Stress Disorder, Chronic. Record of Resident #96 physician orders dated 05/19/23 revealed Cymbalta 60mg by mouth daily for Post-Traumatic Stress Disorder dated 12/14/22. Review of Resident #96's PASRR assessment Level 1 Screening dated 10/13/22, under Section C0100 revealed documentation indicating Resident #96 did not have a mental illness. Review of Resident #96's Annual MDS assessment dated [DATE], revealed under section I Active Diagnoses of Post-Traumatic- Stress Disorder, Chronic. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 13 indicating the resident was mildly cognitively impaired. Record review of Resident #96's most recent care plan, undated, revealed a focus area of Resident #96 was at high risk for side effects due to a diagnosis of Post-Traumatic Stress Disorder. Appropriate interventions are in place to assist with the behaviors associated with Post Traumatic Stress Disorder. During an interview with the ADM conducted on 05/19/23 at 9:48 AM, she said it was the Admissions' nurses' responsibility to review enter PL1 into electronic records. The ADM stated the CMS nurse was responsible for comparing the PL1s to the residents' medical records to ensure accuracy. The ADM confirmed residents #7, #96, #62, #36, and #59 did not have a PASRR Evaluation completed, she also confirmed the PL1s for these residents was not accurate; due to Major Depression and PTSD being diagnoses. The ADM stated the facility does not have a process for updating the PL1 if a resident was diagnosed with a new diagnosis because she did not know the PL1 would need to be updated due to a new diagnosis. The ADM stated she knew PTSD and Major Depression warrant a positive PL1. When asked what the risks for a resident could be if they did not receive an accurate PL1 or subsequent PL2 evaluation, she said the residents are at risk of not receiving proper services. 675874 Page 7 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the MDS Coordinator on 05/19/23 at 9:37 AM, she said Resident #14 had admitted to the facility from home and the PL1 had been completed by a family member. She said the facility staff were still responsible for verifying that the PL1 was accurate. She said Resident #14 had a diagnosis of dementia. When asked if he should have had a positive PL1 due to his diagnosis of MDD she said she was not sure because his PL1 was done in 2020 before she was working at the facility. She said she had a meeting in the past with the local mental health authority to try and get a better understanding of what diagnoses should be triggering a positive PL1 and subsequent level two evaluation. When asked if a diagnosis of dementia would be considered when completing the PL1 or when the evaluation was being completed by the LMHA, she was unsure. 675874 Page 8 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 3 of 29 residents (Residents #98, #101, and #213) reviewed for care plans as follows: *Resident #98 did not have a care plan for urinary and nutritional needs. *Resident #101 was classified as a DNR status and did not have a care plan for DNR status. *Resident #213 did not have a care plan for visual and urinary needs. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include: Resident #98 Record review of Resident #98's face sheet dated [DATE] revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to dementia (progressive loss of intellectual functioning), type II diabetes, schizoaffective disorder (mental health disorder) and urinary tract infection. Record review of Resident #98's physician order summary dated [DATE] revealed the following: [DATE] Regular diet Regular Texture texture, Thin/Regular consistency [DATE] 2.0 Supplement two times a day for supplement (Give 90ml) Record review of Resident 98's Comprehensive MDS, dated [DATE], revealed the following: *Section C BIMS revealed a score of 12, which indicated the resident's cognition was moderately impaired. H0300. Urinary Continence 9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days *Section V Care Area Assessment (CAA) Summary: CAA Results: (06)Urinary (12)Nutritional 675874 Page 9 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #98's care plan, dated [DATE], revealed there was no care plan for urinary or nutritional needs. Resident #101 Record review of Resident #101's face sheet, dated [DATE] revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include dementia (progressive loss of intellectual functioning), Atherosclerotic heart disease (buildup of fats and cholesterol plaque in the walls of the arteries) and anxiety disorder. Record review of Resident #101's admission MDS, dated [DATE], revealed Section C BIMS revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #101's physician order summary dated [DATE] revealed an order Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #101's care plan, dated [DATE], revealed a care area for Advance Care Plan that indicated the following: Focus: Resident/Family/RP does not have advance directives and elects Full Code Status. designating that the resident is a FULL CODE (CPR) status Goal: Community will follow full code status through review date Intervention: Initiate CPR if I am without a pulse . Review code status at least annually and as indicated Further review of the care plan did not indicate a DNR status update. Record review of Resident #101's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under Physician's Statement was undated. At the bottom of the form where it indicates All persons who have sign, acknowledging that this document has been properly completed. Revealed there was no signature from either of the two witnesses and no signature from the notary. Resident #213 Record review of Resident #213's face sheet dated [DATE] revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Parkinson's (a progressive nervous system disease), dementia (progressive loss of intellectual functioning) and dietary vitamin B12 deficiency (anemia/ reduction in red blood cells). Record review of Resident #213's Annual MDS, dated [DATE], revealed Section C BIMS revealed a score of 06, which indicated the resident's cognition was severely impaired. Record review of Resident #213's care plan, dated [DATE], had no care plan for urinary or visual needs. Section B1000. Vision 675874 Page 10 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0656 1. Level of Harm - Minimal harm or potential for actual harm Impaired Section H0300. Urinary Continence Residents Affected - Some 1. Occasionally incontinent An interview was conducted on [DATE] at 11:06 AM, the ADON said she was beginning to work on the care plans on her wing. She said the nurses and the MDS nurses are responsible for the nursing portion of the care plan. She said a care plan was a plan that was initiated with goals and interventions for the residents based on their needs. She said she had been trained in care plans since working at the facility. She said she had not dealt with the memory unit and this is where the residents resided at the time of the interview. She said the triggered areas from the MDS are what went into the care plan. She said she was not aware the facility had had any issues with missing care plans. She said if triggered areas are not care planned, the potential negative outcome could be those care areas could fall through the cracks, which could affect the resident in a way that could result in injury. She said all nursing staff and therapists use the care plan. However, she said she was unsure if the CNA utilized the plan. An interview was conducted on [DATE] at 11:54 AM, MDS A said she was responsible for the residents in hall 700 . She said the residents in questioned resided on the memory care unit and she had worked with them. She said she had been trained regarding care plans and the training was ongoing. She said the training was basic. When asked how she decided what was included in the care plan, she said she included information based on drugs, care area assessments from the MDS, and the resident's diagnosis. When asked if there are systems in place to monitor the completion of care plans, she said audits are done by the DON, regional team, and clinical team. She said she was not aware of any issues with care plans at the time of the interview. She said she expected the care plan to include pertinent information such as medications, care area assessments from the MDS, and resident diagnosis. She said everyone in the building mainly used a care plan, which was a plan of care for what a resident needs or wants. She said the care plan was the best way to take care of the resident on a personal level. She said a potential negative outcome of not including the triggered areas from the MDS was the residents could not get the care that they need. She said DNRs should be care planned accurately because if they are not, then staff may not know the resident's code status. She said then the staff could potentially go against the resident's wishes. When asked what the potential negative outcome for the missed care areas was, she said if a person triggered for urinary, they could be at risk for UTI or even pressure ulcers. She said that if they were triggered for visual, then the resident could be at risk for falls. An interview was conducted on [DATE] at 11:55 AM, the Pharmacy nurse said she had been trained in care plans. When asked what information went into a care plan, she said that she worked the floor often and looked at things more personally. She said she would include pertinent information that came from observations. She said she expected the CAAs from the MDS were care planned. When asked if there was a system to monitor care plan accuracy, she said the corporate team, DON and ADON monitored it. She said she was not aware of any missing care plans. When asked what a care plan was, she explained that every day was different and that different perspectives could be taken when caring for a resident. She said the care plan should be able to be given to staff, and the staff would know the 675874 Page 11 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident on a personal level. She said she expected observations and the CAA triggered from the MDS to go into the care plan. She said anyone who provided care used the care plan to care for the resident. She said a care plan was a simple instruction on how to care for the resident. She said it included their likes, dislikes, and how they like things done. She said it outlined how to care for that specific resident. She said failure to include triggered areas could have hindered the resident's care, ability to perform ADLs or overall quality of life. When asked about DNRs and if they should be care planned accurately, she said the resident's code status should have been planned accurately. She said the potential negative outcome of not care planning the resident's code status accurately then the resident's wishes may not be upheld. When asked specifically for the areas that were not triggered in the resident's care plans, she said if a resident was triggered for urinary and not care planned, then staff would not be aware of the resident's extra care needs, and those needs would not be met. She said if the resident triggered for visual and it was not care planned, the staff would not be aware of the extra care the resident needs in that area. She said that the MDS nurses and the entire IDT were responsible for the completion and accuracy of care plans. An interview was conducted on [DATE] at 11:57 AM, and MDS B said she was responsible for the residents in hall 800. She stated she had been trained on care plans but that it was basic training. When asked how she determined what to put in the care plan, she said she looked at assessments, progress notes and conducted interviews with the resident and the aides. She said she also used the information from the MDS. She said that she used the care area assessments, and if they triggered, those also would go into the care plan. When asked if there was a system in place to monitor the care plans, she said yes and that the facility clinical team, DON, and she and the MDS Nurse A look at one another's care plans. She said she was unaware of any issues with care plans during the interview. She said her expectation was for the care plan to include the triggered CAAs and all the pertinent information she gathered from progress notes, assessments, and interviews with staff. She said the clinical staff used the care plan, which included the resident's dislikes, medications, diagnosis, and who they are. She said the care plan gave the staff a picture of who the resident was. When asked what the potential negative outcome was, she said that failure to care plan for the resident's needs could hinder their care and may not know how to care for the resident as a clinical team. She said DNRs should be care planned accurately. She said if a code status was not care planned accurately, proper care may not have been given correctly. When asked for the specific missed care areas, she said failure to care plan urinary could result in UTI, infections, or skin issues. She said failure to care plan visual for a resident could result in increased falls. An interview was conducted on [DATE] at 12:52 PM, the ADM said the MDS was ultimately responsible for the resident's care plans, but the IDT and direct care also contribute. When asked where the information would come from for the care plan, she said it comes from the CAAs triggered in the MDS. She said she had been trained on care plans to the extent of the ADM. She said it was just a general overview but could not complete an MDS as effectively as an MDS nurse. She said everyone uses the care plan to provide care to the residents. She said if the triggered items are not care planned, they may not have provided the best care for the resident. Record review of the facility's policy Care Plans, Comprehensive Person-Centered, Implemented February 2017, revealed the following documentation: Comprehensive Care Plans The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are 675874 Page 12 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0656 identified in the comprehensive assessment. The care plan will describe: Level of Harm - Minimal harm or potential for actual harm the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; Residents Affected - Some any services that would otherwise be required but that are not provided due to the resident's exercise of rights, including the right to refuse treatment. The comprehensive assessment consists of a variety of data and information elements, including the following: Components of a Comprehensive Resident Assessment The comprehensive assessment allows for the development of plan of care that addresses all of the resident's care needs. It also identifies the interventions that may be required to overcome barriers to the provision of resident care. Vision: Resident's visual acuity, limitations, and difficulties and appliances used to enhance vision Physical functioning and structural problems: Resident's physical functional status, ability to perform activities of daily living, and the resident's need for team member assistance and assistive devices or equipment to maintain or improve functional abilities. Continence: Resident's patterns of bladder and bowel continence (control), pattern of elimination, and appliances used. 675874 Page 13 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

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 PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that 1 of 29 residents (Resident #9) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication: - Resident #9 continued to have a PRN order for Lorazepam concentrate 2mg/ml after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. The findings include: Record review of Resident #9's face sheet, dated 05/17/23, revealed an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Parkinson's (a progressive nervous system disease), dementia (progressive loss of intellectual functioning), atrial fibrillation (irregular or rapid heartbeat that causes poor blood flow),major depressive disorder and Alzheimer's (progressive disease that destroys memory and other mental functions) Record review of Resident #9's quarterly MDS, dated [DATE], revealed Section N - Medication Section

N0410 - Medications Received: B - Antianxiety - Given 7 out of 7 days. Record review of Resident #09's physician order summary dated 05/17/23 revealed an order start date 11/25/22 with an indefinite end date for Lorazepam Concentrate 2 MG/ML Give 0.5 ml by mouth every 2 hours as needed for Anxiety/Agitation Record review of Resident #1's MAR for the past 90 days revealed Lorazepam 1mg give 1 tablet by mouth every 4 hrs. as needed for anxiety was administered on 04/24/23 Record review of the pharmacy consultant book dated March 2023 revealed Resident #9 was receiving hospice, comfort, or palliative care services and had an active order for Lorazepam PRN. The Pharmacy Consultant Recommended the following on 03/02/23: Even with hospice status, these orders would require 14 day stop date or indication of specific duration of therapy. There was no additional notes that indicate the response from the attending physician. Record review of the pharmacy consultant book dated February 2023 revealed the Pharmacy Consultant Recommended the following on 02/02/23: Even with hospice status, these orders would require 14 day stop date or indication of specific duration of therapy. There was no additional notes that indicate the response from the attending physician. 675874 Page 14 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the pharmacy consultant book dated January 2023 revealed that Resident #9 was receiving hospice, comfort, or palliative care services and had an active order for Lorazepam PRN. The Pharmacy Consultant Recommended the following on 01/05/23: Even with hospice status, these orders would require 14 day stop date or indication of specific duration of therapy. There was a handwritten note that indicated, recommendation declined per Attending Physician A and that the order would remain the same. No reason indicated as to why. The Pharmacy Consultant had an order for Haldol (PRN w/o a stop date) and recommended that the medication be discontinued, or a stop date be added. The rationale for this recommendation indicated the following: CMS requires that PRN orders for antipsychotic drugs be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the residence condition and progress to determine if the PRN antipsychotic is still needed. Report of the residence condition from facility staff to the prescriber does not meet the criteria for an evaluation. Record review of Resident #09's progress notes dated 05/10/23 at 12:06 PM, 6:07 PM; 05/03/23 at 11:52 AM, 11:32 AM; 05/01/23 11:06 AM, 3:06 PM; 03/25/23 8:21 AM; 11:22 AM revealed the following: Note Text : LORazepam Concentrate 2 MG/ML Give 1 ml by mouth every 2 hours as needed for Anxiety/Agitation PATIENT WILL REMAIN ON LORAZEPAM WHILE ON ACTIVE HOSPICE CARE PRN Administration was: Effective Author: RN A, RN Nursing - Nursing [e-SIGNED] Record review of Resident #09's progress notes revealed the following progress notes on dated 04/24/23 8:21 AM, 1:33 PM; revealed the following: Note Text : LORazepam Concentrate 2 MG/ML Give 0.75 ml by mouth every 2 hours as needed for Anxiety/Agitation PATIENT WILL REMAIN ON LORAZEPAM WHILE ON ACTIVE HOSPICE CARE PRN Administration was: Effective Author: RN B, RN Nursing - Nursing [e-SIGNED] An interview and observation was conducted on 05/19/23 at 11:06 AM, and the ADON said the nurses were responsible for documenting psychotropic medications. She said monitoring psychotropic medications was important because people could have side effects that come with taking psychotropic medications. She said it could create long-term neurological issues. She said she was not familiar with the 675874 Page 15 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PRN 14-day stop date rule. The ADON reviewed Resident #9's orders and acknowledged the order had no stop date and read indefinite. When asked what the purpose of the 14-day stop date was, she responded, I don't know the exact answer, but I can get the information She said she knew the DON had said 14 days and could not exceed that amount for psychotropic medications. She stated she was new to the facility. She said indefinite means anytime and forever. She said if the pharmacist or the doctor recommended that there should have been a stop date, then the facility should have taken that recommendation. An interview was conducted on 05/19/23 at 11:55 AM, the Pharmacy nurse said the physician was responsible for ensuring the order was just for 14 days for PRN antipsychotics. The facility does not want them to be on the medications indefinitely. She said antipsychotics could have adverse side effects. She said she was unaware any residents were on PRN medications without a 14-day stop date. She said she had been trained on the expectation that PRN antipsychotics should have a 14-day stop date. She said the nurses at the facility were also aware that if they get an order, there should be a 14-day stop date. When asked specifically about Resident #9 being on hospice and the doctor not wanting to change it, she said he said hewould not change it because he was on hospice, and that was one of the hospice meds. The surveyor requested documentation supporting the doctor's refusal to add the 14-day stop date. No additional information provided. An interview was conducted on 05/19/23 at 12:52 PM, the ADM said she was aware of 14 day stop date but was not aware that there were residents in the facility that was on PRN medications without a 14-day stop date. She said the DON and the nurse obtaining the order were responsible for ensuring that the PRN Antipsychotic had a 14-day stop date. She said she was unaware of any residents receiving PRN antipsychotics without the 14-day stop date. When asked about the potential negative outcome, she said those medications could have different side effects. She said she had been trained in general about PRN antipsychotic standards. She said her expectation was for there to be a 14-day stop date on all PRN antipsychotics. She said if the doctor chose not to change, she would call the medical director to see if he could prescribe something else or make it routine. On 05/22/23 at 10:29 AM surveyor attempted to contact Attending Physician A he did not answer a message was left with the surveyor's contact information. An interview was conducted on 05/22/23 at 10:36 AM, the Medical Director said it was important to have the 14-day stop date because research had shown that psychotropic medications contribute to increased death in elderly patients. He said he was unaware of any residents on PRN psychotropics without a 14-day stop date. He said even if the resident was a hospice resident and they had a PRN antipsychotic, they should have still had a 14-day stop date. He said hospice companies generally would not want to pay for anything outside of that. He said there would be no exception to the 14-day stop date for PRN antipsychotic medications. On 05/23/23 at 11:04 AM surveyor attempted to contact Attending Physician A. He did not answer. A message was left with the surveyor's contact information. An interview was conducted on 05/23/23 at 11:06 AM, the Pharmacy Consultant said he was familiar with PRN psychotropics having a 14-day stop date. He said this was important because there are a lot of times when residents do not need those medications after that time period and could experience side effects. He said if the resident does not have the 14-day stop date, then there should still be a stop date with specifications as to why they are exceeding the 14-day stop date. He said he was not at his computer at the time of the phone interview, so he could not speak specifically on the 675874 Page 16 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents in question, but that he has brought to facility staff attention when he does catch PRN psychotropics without a 14-day stop date. He said when he had done this in the past, the staff addressed it immediately. An interview was conducted on 05/23/23 at 02:48 PM, Attending Physician B was unaware any residents were on PRN medication with no 14-day stop date. She said if there were any, she did not order it. She said Resident #9 was on hospice, which would be a hospice issue. She said she provided basic needs but that she was not the person responsible for comfort medications. She said she was unsure of who his hospice doctor was. When asked if, in her experience, if there was an exception made for residents on hospice concerning PRN psychotropic medications, she said she was unsure, but she graduated in 1997. She said they do not receive updates, texts, or emails on any new regulations. She said she would think in a hospice situation that, they would not worry about the potential negative outcomes, such as addiction or abuse, because the resident was dying. She said she was not familiar with strict regulations for hospice patients. An interview was conducted on 05/24/23 at 03:33 PM, and RN A said she was aware of the 14-day stop date for PRN psychotropic medications. She said the 14-day stop date was important because psychotropic medications' effects on the elderly could be detrimental. She said it was her understanding when a person was in hospice, this was not the case because the focus was keeping the resident comfortable. She said each time there was a progress note in the electronic medical record regarding the PRN Lorazepam, the PRN medication was administered. She said she has not spoken with the hospice doctor. When asked why medication administration was not on the MAR, she said it should have been. She said once the medication was checked on the MAR, which was what generated the progress note. She said she was unaware of why it would not appear on the MAR. On 05/26/23 09:54 AM surveyor attempted to contact Attending Physician A. He did not answer. A message was left with the surveyor's contact information. Record Review of the Pharmacy Consultant book included the following document: Quality improvement: Consultant Pharmacist Summary dated 03/01/23-03/31/23 signed by the Pharmacy Consultant on 03/22/23 revealed the following: Psychotropic Drugs (d) documentation is appropriate for PRN non-antipsychotic psychotropic drug used greater than 14 days: No irregularities observed. (e) PRN antipsychotic drug use does not continue beyond 14 days without prescriber assessment and new order: No irregularities observed. Record Review of the Pharmacy Consultant book included the following document: Quality improvement: Consultant Pharmacist Summary dated 02/01/23-02/28/23 signed by the Pharmacy Consultant on 02/26/23 revealed the following: Psychotropic Drugs (d) documentation is appropriate for PRN non-antipsychotic psychotropic drug used greater than 14 days: No irregularities observed. 675874 Page 17 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0758 Level of Harm - Minimal harm or potential for actual harm (e) PRN antipsychotic drug use does not continue beyond 14 days without prescriber assessment and new order: No irregularities observed. Limiting the use of PRN Psychotropic Medications dated June 2018 revealed the following: Residents Affected - Few PRN use of psychotropic is limited to 14 days. The psychotropic orders may be extended beyond 14 days if the prescribing practitioner: believes it is appropriate to extend the order, and provides a specific duration of use (this could be indicated by a stop date listed on the MAR), and documents clinical rationale for the extension. There are no exclusions for PRN psychotropic orders once the resident is admitted to a nursing facility. Inform all prescribing practitioners including Hospice care agencies that new orders for PRN and psychotropic medications must comply with CMS requirements. Record Review of facility policy, Psychotropic Medications & Gradual Dose Reduction revised January 2023 STANDARDS The community is expected to make every effort to comply with state and federal regulations related to the use of psychotropic medications in the community to include diagnosis, targeted behavior or clinical indications for use, prescriber's specified dosage frequency and duration of therapy, consent must be received and noted in the medical record for any use of psychotropic medications. Additionally, the prescriber must provide specific rational for use, clinical indications for use, risks and/or benefits of therapy and informed consent as per defined content in the Texas 3713 form for all antipsychotic or neuroleptic drug therapy. o o The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. PHARMACIST and/or CONSULTING PHARMACIST 1. Monitors psychotropic drug use in the community to ensure that medications are not used in excessive doses or for excessive duration. 2. Notifies the physician and the nursing management team if whenever a psychotropic medication is past due for review. Record review of the facility's policy titled Pharmacy Services: Provision of Medications and Biologicals with a revised date of November 2023 revealed the following: Compliance Guidelines 675874 Page 18 of 19 675874 05/19/2023 Lamun-Lusk-Sanchez Texas State Veterans Home 1809 N Hwy 87 Big Spring, TX 79720

F 0758 Level of Harm - Minimal harm or potential for actual harm The community is responsible for the timely acquisition and administration of medications and biologicals. A drug, whether prescribed on a routine, emergency, or as-needed basis, must be provided in a timely manner. Pharmacist service consultation Residents Affected - Few Pharmacist and consultant reports The consultant pharmacist submits a monthly report to the director of nursing that identifies the existence of problems, issues, or irregularities with recordkeeping and the acquisition and dispensing of medications. Within three (3) business days of conducting a drug regimen review, the pharmacist will provide a summary report to the attending physician and the community's director of nursing who (a) documents no irregularity was identified, or (b) reports any irregularities. The pharmacist and community agree on a procedure to apply when an attending physician does not respond to such report or fails to document the basis for his/her disagreement with such report. The report also suggests changes to resident drug regimens and updates the community of the latest regulatory news (e.g., medications approved or not approved for certain diagnoses, restrictions, or warnings on use). The director of nursing advises the attending physician of any suggested drug regime changes. Neither the director of nursing nor the attending physician is required to agree with or implement the consultant pharmacist's recommendations. Unless state law requires an explanation of acceptance or rejection, neither the director of nursing nor physician is required to provide a rationale for not implementing the recommendations. However, there will be documentation that the director of nursing and attending physician reviewed the report and acted. Repeated or frequent rejections of the consultant pharmacist's recommendations indicate that there should be a review the community's drug management program. 675874 Page 19 of 19