Health inspection·March 14, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 resident (CR # 212) of 6 residents reviewed for physician's orders received treatment and care in accordance with professional standards of practice . Residents Affected - Few -CR #212 had an order dated 03/08/2024 for a treatment for his left heel and for heel protectors to be applied. -The facility did not transfer the order to the eTAR, resulting in the resident not receiving the treatments for three days. The deficient practice could place residents at risk for additional skin breakdown. Findings include: Record review of the admission Record for CR #212 (printed 03/13/2024) revealed he was [AGE] years old and was originally admitted to the facility on [DATE]. He was most recently readmitted to the facility on [DATE]. Diagnoses included, but were not limited to, right hip fracture, abnormalities of gait and mobility, and generalized muscle weakness. Record review of the Physician's Order dated 03/08/2024 at 3:59 p.m. revealed Claen (sic) left heel area with normal saline and apply skin prep to to left heel area and apply heel protectors. Record review of the March 2024 eTAR for CR #212 revealed the order had not been transcribed onto the eTAR. In an interview via telephone on 03/13/2024 at 2:40 p.m., a Personal Care Home representative for CR #212 said the facility had attempted to discharge the resident on 03/08/2024. She said the resident had a non-healing wound on his left heel. She said the facility had said it was a scab. She said there was no wound care order at that time. The resident was discharged on 03/11/2024. In an interview on 03/13/2024 at 4:40 p.m., ADON A said CR #212 had an issue with his heel prior to admission. She said it was scabbed over. In an interview on 03/13/2024 at 4:41 p.m. LVN B said the resident readmitted with scabs, and they were monitoring. When asked about the Physician's Order dated 03/08/2024 to clean CR #212's left heel, apply skin prep and heel protectors, LVN B said the order should have been transferred to the eTAR. Page 1 of 10 675901 675901 03/14/2024 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0684 Level of Harm - Minimal harm or potential for actual harm In an interview on 03/13/2024 at 4:42 p.m., ADON A said the Personal Care Home had requested the order for the left heel on 03/08/2024. In an interview on 03/13/2024 at 4:43 p.m. the DON said the order was in the eTAR. At that time ADON C performed a search of CR #212's March 2024 eTAR and confirmed the order had not been transferred. Residents Affected - Few The facility policy Pharmacy Services/Nursing Services Subject: Physician Orders (revised March 2023) read, in part, .6. Medication, treatment, or related orders are transcribed in the eMAR or eTAR, 675901 Page 2 of 10 675901 03/14/2024 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 1 resident (Residents #90) reviewed for pharmacy services. The facility failed to ensure RN D administered Lorazepam (a controlled medication that treats anxiety) to Resident #90 in accordance with physician orders. The facility failed to ensure the reconciliation of controlled drug sheets compared to MAR for Resident #90 to ensure every controlled drug that was administered and documented as administered in the MAR reflected the correct quantity on the controlled drug/disposition form. These failures could place residents at risk of medication error and drug diversion due to not reconciling every shift nor accounting for all controlled drugs administered and/or wasted. The findings included: Record review of Resident #90's face sheet dated 03/14/24 indicated Resident #90 was a [AGE] year-old male who admitted on [DATE] with the following diagnoses: Chronic Diastolic Congestive Heart Failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), Gastro-Esophageal Reflux Disease without Esophagitis (condition in which the stomach contents move up into the esophagus), Anxiety Disorder (ongoing worry and tension may be accompanied by physical symptoms, such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping), and Essential Hypertension(When the pressure in your blood vessels is too high, 130/80 mm Hg or higher). Resident was admitted to the facility for Long Term and Hospice Care. Record review of the MDS assessment dated [DATE] revealed a BIMS summary score of 15, indicative of being cognitively intact. Record review of Telephone Order dated 03/05/24 for Lorazepam (anti-anxiety medication) oral .5mg tab by mouth every 6 hours as needed for anxiety for 14 days. Record review of the Medication Administration record from March 9 - 13, 2024, for Resident #90 revealed the following medication documentation on the MAR: *03/09/24 10:00 p.m. Lorazepam.5mg tab administered *03/10/24 1:22 a.m. Lorazepam.5mg tab administered *03/11/24 1:43 a.m. Lorazepam.5mg tab administered *03/11/24 3:19 p.m. Lorazepam.5mg tab administered 675901 Page 3 of 10 675901 03/14/2024 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0755 *03/12/24 2:50 p.m. Lorazepam.5mg tab administered Level of Harm - Minimal harm or potential for actual harm *03/13/24 7:31 a.m. Lorazepam.5mg tab administered *03/13/24 5:32 p.m. Lorazepam.5mg tab administered Residents Affected - Few There was no active order for Lorazepam (Ativan) 1 mg tab by mouth every 12 hours until 03/13/24 at 10:00 p.m. However, the form titled Controlled Drug Receipt/Disposition form for Lorazepam 1mg tabs revealed: *03/09/24 10:00 p.m. Lorazepam 1mg tab administered *03/10/24 1:22 a.m. Lorazepam 1mg tab administered *03/10/24 3:54 a.m. Lorazepam 1mg tab administered *03/11/24 1:43 a.m. Lorazepam 1mg tab administered *03/11/24 3:22 p.m. Lorazepam.5mg tab administered *03/12/24 4:38 a.m. Lorazepam.5mg tab administered *03/12/24 2:55 p.m. Lorazepam.5mg tab administered *03/13/24 7:51 a.m. Lorazepam 1mg tab administered *03/13/24 5:44 p.m. Lorazepam 1mg tab administered Record review of the form titled Controlled Drug Receipt/Disposition form for Lorazepam 1mg tabs revealed missing .5 mg waste for the following dates and times: 3/9/24 at 10:00 p.m. 3/10/24 at 1:22 a.m. 3/11/24 at 1:43 a.m. 3/12/24 at 2:50 p.m. 3/13/24 at 5:32 p.m. Record review of the Progress Notes revealed additional Lorazepam medication administration did not correspond with the eMAR or Controlled drug receipt/disposition form. These dates and times include: 03/11/24 6:25 a.m. Lorazepam.5mg tab administered 03/11/24 6:14 p.m. Lorazepam.5mg tab administered 675901 Page 4 of 10 675901 03/14/2024 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0755 03/12/24 4:40 p.m. Lorazepam.5mg tab administered Level of Harm - Minimal harm or potential for actual harm 03/13/24 1:35 a.m. Lorazepam 1mg tab administered Residents Affected - Few In an interview on 03/14/24 at 10:32 a.m., the Hospice RN stated that Morphine in conjunction with Lorazepam was extremely common for residents with agitation. She said, We don't have a max dose of Lorazepam in Hospice. We give whatever it takes to make them comfortable. I was called yesterday to assess the resident, and I gave a dose of 1 mg of Ativan from the facility's med cart, and what I gave to the resident yesterday was actually a very mild dose. Morphine in conjunction with Ativan is like a standing order. The nurse was asked if she ordered the .5 mg from the pharmacy, and she stated that she did order the .5 mg Lorazepam from a pharmacy called Long Term Care or Pharma Care. In an interview on 03/14/24 at 10:37 a.m. with the Pharmacy Manager at Pharma Care (LTC Pharmacy), he stated that they never received an order for the .5 mg of Lorazepam and only received the Lorazepam 1mg order. The pharmacy distributed Lorazepam 1mg on 12/28/23 (quantity of 10 tabs) and 03/12/24 (quantity 60 tabs) in a blister pack per the physician's order. In an Interview on 03/14/24 at 2:39 p.m. with the Hospice Nurse Manager, she stated that it is common to order Ativan 1mg every hour for Hospice residents. She stated that this is a Physician order, but it's not considered a standing order. This Lorazepam order is often in combination with Morphine, and it is not uncommon because it will keep him safe, minimize his ability to hurt himself, and also relieve pain. In an interview on 3/14/24 at 2:42 p.m. with the DON, she stated that the resident has had a change of condition since being hospitalized last week and has been getting Lorazepam for agitation. He was currently on Hospice, and they prescribed the medication. She stated that there was an order for both Ativan .5mg and 1mg. She was referred to an order that showed that the Lorazepam was not ordered until 03/13/24. DON said, If we didn't have an order for 1mg of Ativan, it must be a documentation error, and this can be a concern because we are not following Doctor's Orders. The DON also said, When nursing staff administer a controlled medication, it should automatically go on the MAR, and you can put supplemental documentation in the electronic medical record when it populates. She said, Point Click Care ([electronic medical record) ] sometimes glitches, so medication administration may be in the progress notes but not on the MAR; however, she would have to find out and come back to me to see why the wasted medication is not correct. In an interview on 03/14/24 at 4:51 with the Administrator, she said, I don't know the process for wasting medications, but they do have to discard medication properly. She initially denied any problems with the electronic medical record. However, she stated that she was made aware that there were charting concerns this morning, and she reported the issue to her IT department when she was made aware of the problem. Record review of the facility policy and procedure titled Pharmacy/Nursing Service Physician Orders revealed that medications shall be administered only upon written order of a duly licensed and authorized to prescribe such drug. The Policy read, in part, .6. Medication, treatment, or related orders are transcribed in the eMAR or eTAR, Review of the policy regarding, Discarding and Destroying Medications revealed in part that medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. 675901 Page 5 of 10 675901 03/14/2024 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for garbage disposal. Residents Affected - Few -The facility failed to ensure the dumpster lid were secured. This failure could place residents at risk of infection for exposure to germs and diseases carried by rodents from improperly disposed garbage. Findings included: Observation on 03/12/24 at 8:32 am, revealed the facility's dumpster area, which was in the front parking area to the right side of the facility. The dumpster on the left side: lid was wide open. Interview on 3/13/2024 at 10:33am, with the Dietary Manager, she said all the workers know they are supposed to close the dumpster sliding door and make sure the lid was closed. She said if the dumpsters were left open it would bring stray cats and animals in the area causing an infection control issue. Interview on 3/13/2024 at 1:35pm, with the Cook, she said if the lid was to remain open to the dumpster rats and stray cats would come around and create a hazard around the facility. Interview on 3/13/2024 at 2:25pm with the Executive Director, she said if the dumpster lid was left open, it can cause an infection control issue. Record review of the Facility's policy dated 2019 indicated: .Chapter 4: Sanitation Infection Control 4-28 . Procedure: 2. Trash will be deposited into a sealed container outside the premises. Record review of the Facility's Food-Related Garbage and Rubbish Disposal policy, revised April 2006 revealed . 2. All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be covered when stored or not in continuous use. 5. Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin. 7. Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter. 675901 Page 6 of 10 675901 03/14/2024 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure clinical records for 2 residents (CR #212 and Residents Affected - Few Resident # 90) of 4 residents reviewed for clinical records were maintained in accordance with accepted professional standards and practices, were complete, and accurately documented. -CR #212 had a treatment order for staff to clean the resident's left heel and apply skin prep, then heel protectors and the treatment order was not transcribed to CR #212's eTAR. -The administration of a PRN anxiety medication to Resident #90 by not documenting Lorazepam .05mg tabs in the eMAR The deficient practice could place residents CR #212 at risk for additional skin breakdown and Resident #90 at risk for having inaccurate records and inadequate care. Findings include: CR #212 Record review of the admission Record for CR #212 (printed 03/13/2024) revealed he was [AGE] years old and was originally admitted to the facility on [DATE]. He was most recently readmitted to the facility on [DATE]. Diagnoses included, but were not limited to, right hip fracture, abnormalities of gait and mobility, and generalized muscle weakness. Record review of the Physician's Order dated 03/08/2024 at 3:59 p.m. revealed Claen (sic) left heel area with normal saline and apply skin prep to left heel area and apply heel protectors. Record review of the March 2024 eTAR for CR #212 revealed the order had not been transcribed onto the eTAR. In an interview via telephone on 03/13/2024 at 2:40 p.m., a Personal Care Home representative for CR #212 said the facility had attempted to discharge the resident on 03/08/2024. She said the resident had a non-healing wound on his left heel. She said the facility had said it was a scab. She said there was no wound care order at that time. The resident was discharged on 03/11/2024. In an interview on 03/13/2024 at 4:40 p.m., ADON A said CR #212 had an issue with his heel prior to admission. She said it was scabbed over. In an interview on 03/13/2024 at 4:41 p.m. LVN B said the resident readmitted with scabs, and they were monitoring. LVN B stated the Physician's Order dated 03/08/2024 should have been transferred to the eTAR. In an interview on 03/13/2024 at 4:42 p.m., ADON A said the Personal Care Home had requested the order for the left heel on 03/08/2024. In an observation and interview on 03/13/2024 at 4:43 p.m. the DON said the order was in the eTAR. 675901 Page 7 of 10 675901 03/14/2024 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0842 Level of Harm - Minimal harm or potential for actual harm At that time ADON C performed a search of CR #212's March 2024 eTAR and confirmed the order had not been transferred. The facility policy Pharmacy Services/Nursing Services Subject: Physician Orders (revised March 2023) read, in part, .6. Medication, treatment, or related orders are transcribed in the eMAR or eTAR, Residents Affected - Few Resident #_90 Record review of Resident #90's face sheet dated 03/14/24 indicated Resident #90 was a [AGE] year-old male who admitted on [DATE] with the following diagnoses: Chronic Diastolic Congestive Heart Failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), Gastro-Esophageal Reflux Disease without Esophagitis (condition in which the stomach contents move up into the esophagus), Anxiety Disorder (ongoing worry and tension may be accompanied by physical symptoms, such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping), and Essential Hypertension(When the pressure in your blood vessels is too high, 130/80 mm Hg or higher). Resident was admitted to the facility for Long Term and Hospice Care. Record review of the MDS assessment dated [DATE] revealed a BIMS summary score of 15, indicative of being cognitively intact. Record review of Telephone Order dated 03/05/24 for Lorazepam (anti-anxiety medication) oral .5mg tab by mouth every 6 hours as needed for anxiety for 14 days. Record review of the Medication Administration record from March 9 - 13, 2024, for Resident #90 revealed the following medication documentation on the MAR: *03/09/24 10:00 p.m. Lorazepam.5mg tab administered *03/10/24 1:22 a.m. Lorazepam.5mg tab administered *03/11/24 1:43 a.m. Lorazepam.5mg tab administered *03/11/24 3:19 p.m. Lorazepam.5mg tab administered *03/12/24 2:50 p.m. Lorazepam.5mg tab administered *03/13/24 7:31 a.m. Lorazepam.5mg tab administered *03/13/24 5:32 p.m. Lorazepam.5mg tab administered There was no active order for Lorazepam (Ativan) 1 mg tab by mouth every 12 hours until 03/13/24 at 10:00 p.m. However, the form titled Controlled Drug Receipt/Disposition form for Lorazepam 1mg tabs revealed: *03/09/24 10:00 p.m. Lorazepam 1mg tab administered *03/10/24 1:22 a.m. Lorazepam 1mg tab administered 675901 Page 8 of 10 675901 03/14/2024 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0842 *03/10/24 3:54 a.m. Lorazepam 1mg tab administered Level of Harm - Minimal harm or potential for actual harm *03/11/24 1:43 a.m. Lorazepam 1mg tab administered *03/11/24 3:22 p.m. Lorazepam.5mg tab administered Residents Affected - Few *03/12/24 4:38 a.m. Lorazepam.5mg tab administered *03/12/24 2:55 p.m. Lorazepam.5mg tab administered *03/13/24 7:51 a.m. Lorazepam 1mg tab administered *03/13/24 5:44 p.m. Lorazepam 1mg tab administered Record review of the form titled Controlled Drug Receipt/Disposition form for Lorazepam 1mg tabs revealed missing .5 mg waste for the following dates and times: 3/9/24 at 10:00 p.m. 3/10/24 at 1:22 a.m. 3/11/24 at 1:43 a.m. 3/12/24 at 2:50 p.m. 3/13/24 at 5:32 p.m. Record review of the Progress Notes revealed additional Lorazepam medication administration did not correspond with the eMAR or Controlled drug receipt/disposition form. These dates and times include: 03/11/24 6:25 a.m. Lorazepam.5mg tab administered 03/11/24 6:14 p.m. Lorazepam.5mg tab administered 03/12/24 4:40 p.m. Lorazepam.5mg tab administered 03/13/24 1:35 a.m. Lorazepam 1mg tab administered In an interview on 03/14/24 at 10:32 a.m., the Hospice RN stated that Morphine in conjunction with Lorazepam was extremely common for residents with agitation. She said, We don't have a max dose of Lorazepam in Hospice. We give whatever it takes to make them comfortable. I was called yesterday to assess the resident, and I gave a dose of 1 mg of Ativan from the facility's med cart, and what I gave to the resident yesterday was actually a very mild dose. Morphine in conjunction with Ativan is like a standing order. The nurse was asked if she ordered the .5 mg from the pharmacy, and she stated that she did order the .5 mg Lorazepam from a pharmacy called Long Term Care or Pharma Care. In an interview on 03/14/24 at 10:37 a.m. with the Pharmacy Manager at Pharma Care (LTC Pharmacy), he stated that they never received an order for the .5 mg of Lorazepam and only received the 675901 Page 9 of 10 675901 03/14/2024 Cambridge Health and Rehabilitation Center 1106 Golfview Richmond, TX 77469

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Lorazepam 1mg order. The pharmacy distributed Lorazepam 1mg on 12/28/23 (quantity of 10 tabs) and 03/12/24 (quantity 60 tabs) in a blister pack per the physician's order. In an Interview on 03/14/24 at 2:39 p.m. with the Hospice Nurse Manager, she stated that it is common to order Ativan 1mg every hour for Hospice residents. She stated that this is a Physician order, but it's not considered a standing order. This Lorazepam order is often in combination with Morphine, and it is not uncommon because it will keep him safe, minimize his ability to hurt himself, and also relieve pain. In an interview on 3/14/24 at 2:42 p.m. with the DON, she stated that the resident has had a change of condition since being hospitalized last week and has been getting Lorazepam for agitation. He was currently on Hospice, and they prescribed the medication. She stated that there was an order for both Ativan .5mg and 1mg. She was referred to an order that showed that the Lorazepam was not ordered until 03/13/24. DON said, If we didn't have an order for 1mg of Ativan, it must be a documentation error, and this can be a concern because we are not following Doctor's Orders. The DON also said, When nursing staff administer a controlled medication, it should automatically go on the MAR, and you can put supplemental documentation in the electronic medical record when it populates. She said, Point Click Care ([electronic medical record) ] sometimes glitches, so medication administration may be in the progress notes but not on the MAR; however, she would have to find out and come back to me to see why the wasted medication is not correct. In an interview on 03/14/24 at 4:51 with the Administrator, she said, I don't know the process for wasting medications, but they do have to discard medication properly. She initially denied any problems with the electronic medical record. However, she stated that she was made aware that there were charting concerns this morning, and she reported the issue to her IT department when she was made aware of the problem. Record review of the facility policy and procedure titled Pharmacy/Nursing Service Physician Orders revealed that medications shall be administered only upon written order of a duly licensed and authorized to prescribe such drug. The Policy read, in part, .6. Medication, treatment, or related orders are transcribed in the eMAR or eTAR, Review of the policy regarding, Discarding and Destroying Medications revealed in part that medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. 675901 Page 10 of 10