Inspection·August 25, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/23/23 at 2:10 pm the IDON said that the Pharmacy A representative told her that Resident #1's Invega injection was requested by the facility on 4/13/23 and delivered on 4/14/23, on 5/13/23 and delivered 5/14/23, and on 6/13/23 and delivered 6/15/23. Record review of Pharmacy A's Packing Slips verified Invega Sustenna 117MG/0.75ML for Resident #1 was delivered to the facility on: 4/14/23 at 4:00 am and was signed for by RN C, 5/14/23 (no time specified) and was signed for by LVN B, and 6/15/23 at 3:47 am and was signed for by LVN B. During an interview on 8/23/23 at 11:29 am LVN A said the number 9 on the MAR meant the medication was not given for some reason and that the reasons were documented in the progress notes. She verified that her initials were [LVN A's initials] and that she documented on Resident #1's MAR a 9 on 4/13/23 and 5/13/23. LVN A said that Resident #1 did not receive the Invega injection on 4/13/23 and 5/13/23 because it was not available, she added that she had ordered it from the pharmacy, but it did not arrive on the day the medication was due to be administered. LVN A stated the facility's nurses were responsible for ordering medications when they were out. LVN A stated she documented in the progress notes that the medication was pending from the pharmacy. LVN A said she did not administer the medication because she was not at the facility when it was delivered. She added that she did not remember but said she was sure she did not work on 4/13/23. She said she was sure the injection was administered because Resident #1 had not had any changes in mood or behavior but could not remember administering the injection. LVN A said the Invega injection's administration should have been documented in the progress notes by the nurse administering it. She added that the nurse that was on shift when the medication was delivered should have administered and documented it. LVN A said she did document that it was not available and notified the NP that the medication was not available. During an interview on 8/23/23 at 1:16 pm the ADON said that he had started working at the facility less than 90 days ago and was not aware that Resident #1 had not received the Invega injection on 4/13/23, 5/13/23 and 6/13/23. The ADON stated there had not been reports from the staff or the NP, who visits the facility every day, regarding changes in Resident #1's mood or behavior. The ADON said it was important that Resident #1 received the Invega injection every month because it affects her mood and behaviors and a lapse in the administration of the medication was not good because it needed to reach a therapeutic level. The ADON said the Invega could not be ordered before the 13th of the month because the insurance did not allow it and only covered the medication when ordered every 30 days. During a telephone interview on 8/23/23 at 3:53 pm the Pharmacist from Pharmacy A said she was not able to find evidence that the insurance rejected payment for the refill of Invega, she added that Resident #1's insurance plan did allow the medication to be filled a few days before it was due to be administered. During an interview on 8/23/23 at 4:25 pm the DON said the software used by the facility did not allow the facility to order the Invega injection until the 13th of every month, which is when Resident #1's Invega injection was due. During an interview on 8/23/23 at 3:25 pm the NP said that he was notified that the medication Invega was not administered to Resident #1 due to it not being available on 4/13/23, 5/13/23, and 6/13/23. He added that the nurses were told to administer the medication as soon as it arrived at the facility. The NP said he saw the resident monthly, and she had been stable, there had not been any changes in mood or behaviors, she had been doing well and had been very pleasant. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675883 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southeast Nursing & Rehabilitation Center 4302 E Southcross Blvd San Antonio, TX 78222 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/23/23 at 5:00 pm LVN A said she has been under a lot of pressure and did not remember if she administered the Invega to Resident #1 in April. During a telephone interview on 8/23/23 at 6:36 pm LVN B stated she received Resident #1's Invega injection on 5/14/23 and 6/15/23. She said that she administered the injection after they arrived. LVN B said that she did not document the administration on the MAR because the slots were filled, and she was not able to check the boxes on the MAR on the day it was administered. She added that she notified the following shift verbally that she had administered the injection but did not document this in the progress notes. LVN B said she was required to document the injection's administration in the progress notes. She added that she had received training regarding medication administration, documentation, communication, and MD notification. LVN B said she received this training upon hire and on 8/23/23. During a telephone interview on 8/25/23 at 8:57 am RN C stated she received Resident #1's Invega injection on 4/13/23 but did not administer it. During a telephone interview on 8/25/23 at 11:00 am LVN D said the number 9 on the MAR meant other. LVN D stated her initials were [LVN D's initials], that she documented on Resident #1's MAR a 9 on 6/13/23 and documented in the progress notes that the medication was pending from pharmacy. LVN D said she was sure that LVN A administered the injection but did not know if LVN A documented the administration. LVN D said that she was sure that LVN A administered it because she took the injection out of LVN D's medication cart and told LVN D that she had forgotten to administer it and was going to administer it. LVN D said she did speak with the NP to get an order for late administration of the Invega injection. LVN D said that there had been no changes in Resident #1's mood or behavior noted or reported. During a telephone interview on 8/25/23 at 11:44 am the Administrator said that LVN A was under a lot of pressure and stress due to all the responsibilities she has been given at the facility. Record review of a facility policy titled, Medication - Treatment Administration and Documentation Guidelines, dated 2/10/2020, revealed the following, document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675883 If continuation sheet Page 3 of 3