Health inspection·August 10, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from of any significant medication errors for 1 of 11 residents (Resident #1) reviewed for medication regimen. Residents Affected - Some The facility did not administer physician ordered medications to Resident #1 that included handheld nebulizer breathing treatments, inhalers, nasal sprays, and tablets for diagnosed respiratory diseases. This resulted in the need for Resident #1 to be transferred to ED on 08/04/2024 at 8:55 PM and admitted to hospital with diagnosis of acute exacerbation of chronic obstructive pulmonary disease (lung disease causing breathing problems) and symptoms of shortness of breath. An Immediate Jeopardy was identified on 08/09/2024. The Immediate Jeopardy Template was provided to the Administrator on 08/09/2024 at 3:40 PM. While the Immediate Jeopardy was removed on 08/10/2024 at 5:41 PM, the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. This failure placed residents at risk of significant medication errors and a decline in health status, serious injury, and/or death. The findings included: Record review of Resident #1's admission Record, dated 08/08/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE] at 03:38 PM. The resident's diagnoses included chronic obstructive pulmonary disease (lung disease causing breathing problems), anxiety disorder (feelings of worry), essential hypertension (high blood pressure), hypothyroidism (thyroid disorder), type 2 diabetes mellitus (elevated blood sugar), long term (current) use of anticoagulants (use of blood thinner), unspecified asthma (breathing disorder caused by airway restriction), gastro-esophageal reflux disease (stomach digestive disease), pain (discomfort), localized edema (swelling in a specific area), allergic rhinitis (allergic response causing sneezing) and hereditary and idiopathic neuropathy (weakness, numbness, pain from nerve damage). Record review of Resident #1's Medication Administration Record, dated 08/08/2024, revealed in part: Brezti HFA 160-9-4.8ncg 2 puffs inhalation twice a day Dx: COPD, inhaled medication to open airways and decrease breathing difficulties (2 of 2 missed doses) Budesonide 0.5mg/2ml 1 vial twice a day Dx: COPD, (an inhaled medication to open airways and Page 1 of 10 675932 675932 08/10/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 decrease breathing difficulties) (2 of 2 missed doses) Level of Harm - Immediate jeopardy to resident health or safety Fluticasone 50mcg 1 spray nasal twice a day Dx: Allergic Rhinitis, (a nose spray for nasal allergies). (3 of 3 missed doses) Residents Affected - Some Ipratropium-Albuterol 0.5mg-3mg/3ml 1 vial via HHN twice a day Dx: COPD, (an inhaled medication to open airways and decrease breathing difficulties) (3 of 3 missed doses) montelukast tablet. 10mg. 1 at bedtime Dx: Asthma, (a tablet to decrease allergy symptoms) (2 of 2 missed doses) Losartan 25mg 2 tablets once a day Dx: COPD, HTN, (a tablet to maintain blood pressure and decrease airway difficulties) (1 of 1 missed doses) Prednisone 10mg once a day (AM) Dx: COPD (1 of 1 missed doses) Albuterol Sulfate HFA Inhaler PRN wheezing/SOB (a breathing inhaler medication to decrease airway difficulties) (was not administered) Record review of Resident #1's Nursing Progress Note, dated 08/03/2024 through 08/04/24, revealed: 08/03/2024 at 09:23 PM, LVN A documented resident's arrival to facility on 08/03/2024 at 5:00 PM, admitted from acute care hospital with diagnosis of peripheral vascular disease and transported via facility van. LVN A also documented admission orders entered into matrix care and medication orders sent to pharmacy at 5:00 PM. 08/04/2024 at 03:49 AM, LVN F documented Resident has heart rate of 122, anxiety, problems breathing. (Physician) notified and he ordered one time order of Clonazepam1mg for resident. Administered at this time. Will continue to monitor. 08/04/2024 at 05:46 AM, RN G documented Repeat vitals,BP131/89,SPO2 98,resp26,pulse 92,Temp 97.8. On oxygen 4L/min at this time. pt still having dyspnea. Will continue to monitor. 08/04/2024 at 09:39 PM, LVN B documented transfer resident to Hospital ER. Primary reason for transfer: shortness of breath, anxiety and husband wanted resident transferred. Resident condition upon transfer alert and oriented with oxygen applied at 3liters per minute. Resident left facility at 08/04/2024 at 9:00 PM. Resident did not have medications in facility d/t not received from pharmacy resident admitted after 1600(4:00PM) on 08/03/2024. Record review of Resident #1's hospital medical record ED Provider note, dated 8/4/24 at 2137 (9:37PM), revealed the following [in part]: Chief complaint of shortness of breath. Vital signs: T-98.5, HR 123, R 23, BP 159/104, SpO2 100%. Physical Exam Comments: Abuse. Chronically Ill. On a non-rebreather mask. Diminished in lung bases. Scattered rales. Blood Gas (lab to detect oxygen, acidity, and carbon dioxide in the blood), Venous Collected 8/4/24 @ 9:30 PM with the following results: Ph Venous - 7.32 (Normal 7.35-7.45), PCO2 Venous 72.0 (Normal 80-100), HCO3 Venous 37.3 (Normal 22-26),CO2- 34 (Normal 23-30). 675932 Page 2 of 10 675932 08/10/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 Hospital admitting diagnosis: Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 08/08/24 at 10:49 AM with Resident #1's Physician, he stated he was at the facility in Resident #1's room at the time of Resident #1's transfer initiation to the ER. He said the resident complained of difficulty breathing and wanted to be transferred to the ER. He stated, I am sure that the lack of medication could have contributed to exacerbation of COPD. He further said the staff at the nursing home usually notified him if the medications were unavailable so he could Give a new order if needed, he continued to say that the clinical staff was in contact with him regarding Resident #1. Residents Affected - Some In an interview on 08/08/24 at 1:18 PM, LVN A, who was the admitting nurse for Resident #1, stated When I went in to assess (Resident #1), she was fine and not short of breath unless she walked to the restroom. She did have an inhaler that her husband brought from home that she used, but I have no idea what it was, (resident's husband) put it back in his pocket. I think it was blue. I suppose it would be me and (other nurse) that should order medication, I only work a few days, so I am not sure. When I received the order, me and the other nurse put the orders in and as far as I know that is what triggers the pharmacy to deliver the medication. I don't give scheduled medications only controlled medications. I knew (Resident #1) didn't have anything upon arrival for meds, I think they have a thing in the med room that they can pull from. All of the orders were put in, I thought they would be delivered at 12 am. In an interview on 8/08/24 at 1:32 PM, LVN B stated Sometimes admission orders are faxed in advance from the hospital, and sometimes they are sent with the resident in a packet when they arrive at the facility. We cannot enter any orders into the computer until the resident is in the building. We cannot enter orders until the resident is entered in the census to open a chart. When the orders are entered into the chart, they automatically are sent to the pharmacy. As long as orders are entered in the computer before 6:30 PM, they should be delivered that same night, but they're not delivered. The orders aren't received immediately by the pharmacy. If the meds aren't delivered, then the nurse gets them from the emergency box, (EMDS). The medication aide administers new residents' meds, except insulin, breathing treatments of any kind (inhalers, nebulizer treatments, supplemental oxygen), PRN narcotics. Med aides can give routinely scheduled narcotics, just not PRNs. Medication aides reorder routine meds when they get low. There is a column on the right-hand side of each medication on the eMAR that says resupply and the medication aide just clicks on it to reorder. The licensed nurses reorder narcotics because the pharmacy has to be called. LVN B stated she called the doctor to ask if medications have refills or if a prescription could be written to send to the pharmacy. LVN B stated she worked for an agency not the facility, has worked in facility for about 2 weeks averaging 4 days per week and doesn't work weekends. LVN B stated the agency nurse was assigned whatever hall was open, including the Medicare Hall, Hall A. She admitted a resident to the Medicare Hall A, entered meds in the computer, and completed the admission nursing assessment, a standardized form. During the week, the ADONs and the DON would help with the admission process and would sometimes enter the medication orders. In an interview on 08/08/24 at 1:51 PM, ADON H stated the Charge Nurse was responsible for ordering medications and if they could not get the medication after calling the pharmacy, they should have notified administrative staff to give direction on what to do. ADON H stated the failure of Resident #1 not getting her medication could have occurred because of a lack of knowledge maybe. ADON H said the risk of the failure for Resident #1 not receiving her medications was an Exacerbation of her Chronic Diseases. 675932 Page 3 of 10 675932 08/10/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In an interview on 08/08/24 at 2:02 PM, ADON I stated the medication aide should have notified the nurse that Resident #1's medication had not been delivered in the medication cart and the Nurse did not follow through to make sure Resident #1 got her medication. ADON I said she did not realize Resident #1 had not received any of her medications for 08/03/24 or 08/04/24 until the morning of 08/08/24. ADON I said the Charge Nurse and the medication aide lacked initiative to get the medication which caused the failure. She said if it were her, I would have pulled everything possibly from the (EMDS) and then contacted the pharmacy to have the rest delivered from backup. ADON I said that did not occur because, PRN nurses, either didn't know the process or just didn't follow it. ADON I stated it was the responsibility of the med aide, nurse, nurse on call, DON ADM to order medications for a new admission. ADON I stated the failure could include death for a resident. In an interview on 08/08/24 at 3:50 PM the DON, stated training began on 08/05/24 with the anticipated DON, start date of 08/12/24. The DON further stated Resident #1 did not receive any of her medications for 08/03/24 or 08/04/24, but the facility did not realize Resident #1 did not receive any of her medications until after the State Surveyors began the investigation and the facility began a Chart Audit after 6ish Wednesday (6:00PM 08/07/24). The DON said (Resident #1) should have received her medications and the on-call nurse, DON, MD should have been immediately notified if the medications were not available. The DON stated the failure occurred because, lack of communication, agency LVN, and admission process. The DON stated the ADON and the LVN had access to the EMDS, and (facility) were working on getting all facility employed nurses' access to the system. The DON stated nurses were responsible for providing residents with nebulizers, inhalers and nasal sprays. In an interview on 8/08/24 at 4:10 PM, MA D stated the licensed nurses give the initial dose of medications. If a resident is new to the facility, then all their medications are considered initial doses, and the Med Aide doesn't do it. MA D stated I did not give Resident #1 any medications. Medication Aide D said The nurses put the orders in the computer for the pharmacy and the licensed nurses give the initial doses and all the PRN medications. The nurses can get meds from (EMDS) (EMDS), but the med aides cannot. I did not see LVN A give Resident#1 any medications and I don't know if she (LVN A) gave the resident any medications. MA D stated the resident did not have any medications in the med cart because she didn't come with any. MA D also stated Medication Aides do not do any kind of respiratory care or breathing treatments - no inhalers or nebulizer treatments. The med aides can get the oxygen cylinder, but the nurse sets the liters and applies the oxygen. In an interview on 08/08/24 at 4:27 PM the Clinical Resource Nurse stated the medications were ordered, but the pharmacy should have been called to ensure the orders were filled, the medication should have been obtained from (EMDS) and what isn't obtained from (EMDS) the pharmacy should have been called, the physician should have been called, or you could call the family to see if they have home medications, we could have gotten medication from hospital, we could have notified DON. The Clinical Resource Nurse said the nurse didn't administer Resident #1's medications from the EMDS because, I am not sure why she didn't give them, but there were many opportunities for her to seek the assistance to obtain the medication. The Clinical Resource Nurse stated the failure could have occurred because of a lack of education, further stating the nurses were responsible for initial doses of medications, nebulizers or breathing treatments and inhalers. The Clinical Resource Nurse said the failure could have caused the rehospitalization of Resident #1. In an interview on 8/8/24 at 4:44 PM, the Administrator stated, the facility failure was that they did not check the (EMDS) and did not notify nursing management that they were missing all of those medications, as well as the charge nurse. The Administrator stated I know I got a call Sunday about an uber and picking up medication how to pay an uber, I said no the pharmacy orders thru a local 675932 Page 4 of 10 675932 08/10/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some pharmacy they take care of it, at that time I called ADON I, at that time I was aware of the clonazepam only. Otherwise, I didn't know of anything else until yesterday . I was not aware of other medications not given until yesterday evening. Record review of the facility's policies/procedures for Medication Orders revealed [in part]: Non-controlled Medication Orders, 12/12 Procedures - Elements of the Medication Orders 4. The prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available. Documentation of the Medication Order: a. New orders b. Written transfer orders (sent with a resident from a hospital or other health care facility): Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. 4. Scheduling new medications orders on the Medication Administration Record (MAR)/Treatment Administration Record (TAR): a. Non-emergency medication orders: The first dose of medication is scheduled to be given after the next regularly scheduled pharmacy deliver to the nursing home. b. Emergency/STAT medication orders when medication is available in the emergency kit: From the emergency kit, remove the appropriate number of doses to be administered prior to the regularly scheduled pharmacy delivery. Thereafter, does are scheduled according to nursing care center policy on medication administration. c. Emergency/STAT medication order when medication is not available in the emergency kit: An emergency STAT order is placed with the provider pharmacy and the medication is scheduled to be given as soon as received. Subsequent doses are timed according to nursing care center policy on medication administration schedule. This was determined to be an Immediate Jeopardy on 08/09/2024. The Administrator was provided the Immediate Jeopardy Template on 08/09/2024 at 3:49 PM and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 08/10/2024 at 10:17 AM: 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #1 was sent to the hospital on 8/4/2024. Person(s) Responsible: Charge Nurse/The Physician/The Facility 675932 Page 5 of 10 675932 08/10/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 Level of Harm - Immediate jeopardy to resident health or safety 2. How the Facility Identified Other Possibly Effected Residents: Residents Affected - Some Action: Facility wide MAR to cart audit to ensure medications on the MAR are available on the medication carts, including recent admissions/readmissions. This has been completed on 8/9/2024 with no other discrepancies noted. Person(s) Responsible: Regional Nurse, Director of Nursing, Assistant Director of Nurses and/or Designee 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Director of Clinical Operations and Clinical Resource Nurse educated Director of Nursing and Assistant Director of Nurses regarding the facility's emergency medication dispenser and ordering medications from the pharmacy. Charge Nurses were educated by the Clinical Resource Nurse, Director of Nursing, and/or Assistant Director of Nurses over the facility's emergency medication dispenser, ordering medications from the pharmacy. Charge Nurses and Certified Medication Aides were educated over their responsibilities in administering medications and initial doses and notifying the physician with any medications that are unavailable through the emergency medication dispenser and/or would be delayed in receiving and following MD orders. If the medication is not available in the Emergency (EMDS) the nurse will notify the Pharmacy On Call that the medication is not available in the Emergency (EMDS) and determine if the provider pharmacy will be filling the medication order or they will be sending the order to a local 24-hour pharmacy for fill and arranging delivery or pick up. The nurse will determine an approximate time of delivery and document this is the progress notes. Charge Nurses/Certified Medication Aides will be educated prior to working their next shift. New and temporary Charge Nurses/Certified Medication Aides will be educated prior to working their first/next shift. Person(s) Responsible: Director of Clinical Operations, Clinical Resource Nurse, Director of Nurses, Assistant Director of Nurses, and/or Designee 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Review all admissions/readmissions to ensure medications are available during clinical meetings, daily. 675932 Page 6 of 10 675932 08/10/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Charge nurses will communicate with the Director of Nursing, Assistant Director of Nursing, and/or Administrator and Doctor if medications are not available immediately from the emergency medication dispenser for the next administration time for all admissions/readmissions regardless of day or time and/or pharmacy is unable to deliver the medications timely/on the next run, immediately through the above education. Residents Affected - Some Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Charge Nurses, and/or Designee Action: Medication unavailable report to be ran and reviewed during clinical meetings, Monday-Friday, staff will know to communicate unavailable medications with the Director of Nursing, Assistant Director of Nursing, and/or Administrator and notification of the MD through the above education if there is a noted issue with medications being unavailable. Any issues noted with medication unavailable/failure to communicate will result in 1:1 education with the Charge Nurse or Certified Medication Aide responsible. Director of Nursing, Assistant Director of Nursing, Charge Nurses, and/or Designee Action: Notify the MD/Ad hoc QAPI regarding the deficient practice and the facility's plan to avoid future noncompliance. Person(s) Responsible: Administrator/Director of Nursing Monitoring and Verification of the facility's Plan of Removal began 08/10/2024 at 10:19 AM as follows: In an observation on 08/10/2024 at 1:39 PM, 3 medication carts were inspected and 3 of 3 new admission residents medications were available on the cart and were administered as ordered. In an interview on 08/10/2024 at 11:09 AM, LVN N stated Upon admission orders are brought to facility, put in computer, pharmacy is called, then pull medications from EMDS. The CMA should inform the nurse if there are no medications on the cart to be given to the resident, then the nurse would have gone thru the EMDS, called the pharmacy and then administered. If the CMA does not communicate to the nurse the nurse would not know. LVN N further stated, if an issue with a medication, LVN N immediately calls the pharmacy to get the medication. LVN N stated I received training regarding responsibilities of Charge nurse, I have been here three years, we (nursing staff) got another training yesterday (8/9/24) that was provided by DON. Yesterday we reviewed the EMDS, physician orders, notifying physician regarding medications that are unavailable and get a suitable substitute, nurses providing initial doses. DON reviewed this with me one on one and I felt comfortable asking questions. In an interview on 08/10/2024 at 01:21 PM, MA D stated she was in-serviced by ADON I, face to face on Medication Administration, which included if a new admission comes in the initial dose is to be 675932 Page 7 of 10 675932 08/10/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some given by the charge nurse and that the nurses set up all of the oxygen stuff as well. MA D further stated If there is a resident on my cart I tell the nurse they do not have medication and to remind them to pull from EMDS. In an interview on 08/10/2024 at 1:39 PM, MA E stated in-service training provided in the past day regarding medication administration, new admission medication, to notify nurses if missing medications, that only nurses initial dose,the EMDS that nurses could retrieve medications from. MA E stated she received one on one training from the DON and was able to ask questions. MA E further stated if there was a medication ordered, MA E immediately told the nurse it was not available. In an interview on 08/10/2024 at 1:52 PM, LVN K stated an in-service by the DON and the ADON one on one with each regarding EMDS use of and what was available, admissions, medication ordering and physician notification. LVN K stated nurses were responsible for the initial dose. LVN K further stated Medications for new admissions, I would order from pharmacy and use EMDS if I need so that no doses are missed and if it's a resident that is already here I would check to make sure overflow and pull from STAT EMDS box to avoid missing a dose. In an interview on 08/10/2024 at 2:13 PM, MA M stated an in-service was given by ADON I, one on one regarding initial doses, and notification to nurse if medication needed was not available. In an interview on 08/10/2024 at 2:17 PM, LVN L stated an in-service completed by ADON I, one on one, regarding EMDS demonstration, initial dosing, HHN, new admission responsibility of orders and medications, procedure if medications were not available in the EMDS, notify pharmacy, physician and clinical staff. In an interview with Clinical Resource Nurse on 08/10/24 at 4:02 PM revealed Resident #1 was transferred to the hospital on [DATE] from the facility. The CRN stated she did the chart audits on 08/09/24 and any medications that were low were ordered from the pharmacy and/or restock was completed. The CRN explained in-services completed with staff consisted of ordering medications for admissions and readmissions, accessing and use of EMDS with demonstration, and ordering routine medications for all residents in the facility's new and current, reviewed notification of doctor, DON, ADON and ADM if any medications were unable to be obtained, always including weekends and after hours. The information provided to the licensed nursing staff specified if a medication could not be found in the medication cart it could be found in the EMDS. Charge nurses employed by facility may access the EMDS. Agency staff should ask for assistance obtaining medication needed from the EMDS which included tablet, capsule, liquids, HHN and injectables. A copy of the EMDS manufacturer Quick Reference Guide was reviewed with the nurses and gave specific step-by-step instructions on how to operate the medication dispensing machine with pictures of power-point slides. A printed list of the Active Inventory of medications in the EMDS for the facility. The staff did return demonstration of use of the medication dispense machine. She said, facility DON or designee will run a report Monday thru Friday mornings of medications not given. The DON would then bring the report to morning meeting to discuss with the team. The DON or designee would initiate an investigation, speak with the nurse or CMA who was responsible, find out why the medication wasn't administered, educate them, and follow the discipline policy as needed. In an interview on 08/10/24 at 4:37 PM, the DON stated the DON and both ADON's in-serviced all facility charge nurses regarding log in access to EMDS with demonstration regarding how to use system, initial dosing must be completed by license staff only, admission and re-admission medication process, ordering and dispensing, the CMA scope of practice. The DON explained in further detail the DON 675932 Page 8 of 10 675932 08/10/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and the ADON educated clinical staff regarding upon admission that all resident medications should be reviewed for verification that medications were available for supply, the DON or ADON must be notified if not able to supply for next steps such as notifying the discharge provider for alternate or to send with supply, initial doses were only to be given by licensed nursing staff, the CMA expectation was not to administer initial doses and they were to notify the charge nurse of any medications not available to them. The DON further explained above information was given one on one to each facility nurse and facility CMA. The DON also stated the DON was responsible for education regarding the in-services and education given to clinical staff, she, with the help of the ADONs and the Clinical Resource Nurse completed trainings. The DON stated the process to address all new referrals and new medication orders in the morning meetings, as well as the DON or the on call clinical designee would call in on weekends to verify. The DON stated, medication unavailable report will be reviewed daily Monday thru Friday in morning meeting. If anything is flagged, DON will review, investigate, and determine why medication was missed or not given and then take corrective action as appropriate. She said The process to address all new referrals and new medication orders in the morning meetings, as well as DON or the on call clinical designee will call in on weekends to verify. In an interview on 08/10/2024 at 5:00 PM with the DON, she said they had a QAPI meeting and attendance with the medical director via phone. The Medical director was called by the ADM. Interview also revealed that Medical Director was notified by the DON regarding medications not administered to Resident #1 on 08/08/24 at 10:53AM. In an interview with ADM 08/10/2024 at 5:02PM regarding physician notification of Medical Director regarding IJ and SQC, ADM stated that medical was notified by ADM via phone on 08/09/24 at 5:11PM. Record review of Resident #1 hospital record dated 08/04/24 at 9:42 PM, revealed Resident #1 arrival to the emergency department with symptoms of shortness of breath at 9:15 PM on 08/04/2024. In an interview on 08/10/24 at 10:21am, with Resident #1's family, she said Resident #1 discharged from the hospital on [DATE] to a different nursing facility and was feeling much better. Record review of Chart Audit, dated 08/09/24, revealed All Medication Carts were audited and completed as signed by CRN and dated 08/09/24. Record Review of In-services dated, 08/08/24 & 08/09/24, included the following: Initial Dosing-8/9/24Certified Medication Aide (CMA) are not to administer the initial dose of any medication. This includes newly admitted residents and residents who have orders for any new medication. Initial dosing medication is not within the scope of practice of a CMA. This inservice had facility staff signatures and facility staff names and phone numbers indicating nurses and medication aides were inserviced on the information. New Admit Readmit Med Process Med Dispense Machine-Nurse Administrative Staff-8/9/24. 1. New admission Medication 2. Med Dispense 3. Nebulizer Med Administration dated 8/9/24-Admission/readmission Medication Process- Always including nights and afterhours-1. Enter orders for residents hospital discharge medication list. 2.Contact the pharmacy to confirm medication time of arrival 3. Enter pharmacy communication information in a nurse's note. Include name of person that was spoken to at pharmacy. 4.Check the medication dispensing machine for available medications. 5. At this time notify doctor, director of nursing, assistant director of nursing, or administrator of any 675932 Page 9 of 10 675932 08/10/2024 Avir at Arbor Terrace 609 Rio Concho Dr San Angelo, TX 76903

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some medication that is unavailable, to obtain a substitute medication or in order to DC the medication until it is available from the pharmacy. And alternate pharmacy may be considered (local pharmacy) 6. Communication with director of marketing, to request discharge medication for medication that is unavailable prior to discharge. 7. In the morning meeting review referral documentation. communicate with the director of marketing to request discharge medication for medication that is unavailable prior to discharge. Consider holding admission if it is foreseen that we will be unable to attain medication including after hours or on weekends. 8. The morning following admission the DON or designee will verify the medications were obtained. - Nursing staff signatures reflected they reviewed and acknowledged the information. Accessing medication from med dispense located in the med room at the nurses station medication that cannot be found in the medication cart can be found in the Med dispense. Charge nurses employed by (facility) may access the Med dispense machine agency staff should ask for assistance obtaining medication needed from the medication dispense machine including tablet, capsules, liquids, HHN, injectables. Nursing staff signatures reflected they reviewed and acknowledged the information. 1 ·The Director of Nursing/designee will review referrals preadmission specifically those that may be admitting after hours/weekends and request potential discharge date and time and discharge orders if these are available.2· The Director of Nursing/designee will determine what medications are needed and specifically note if any medications will not be available in the facility's emergency medication dispenser (review the referral prior to admission, communicate with the discharging entity on potential discharge date (s), proactively request discharge orders from the discharging entity).3. If the Director of Nurses/designee identifies medications that are not in the Emergency medication dispenser and if this medication will be needed prior to the next Pharmacy delivery the Director of Nurse/designee will request the discharging entity to provide medications until the facility can obtain the medications. If the discharging entity is unable to supply the medication{s) the facility will notify the physician and determine further actions or delay the admission until the medication can be obtained.- Nursing staff signatures reflected, they reviewed and acknowledged the information. Medication unavailable report to be ran and reviewed during clinical meetings, Monday-Friday, staff will know to communicate unavailable medications with the Director of Nursing, Assistant Director of Nursing, and/or Administrator and notification of the MD through the above education if there is a noted issue with medications being unavailable. Nursing staff signatures reflected, they review[TRUNCATED] 675932 Page 10 of 10