Health inspection·September 19, 2024

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to act upon the pharmacist's drug regimen review irregularity reports for two of (Residents #1 and #2) of seven residents reviewed for medication consents. 1. The facility failed to respond to the pharmacist's notification that Resident #1's Trazodone (an antidepressant and sedative medication used to treat depression and may also be used for other conditions) consent was missing and needed to be obtained and uploaded. The facility had an unsigned written consent from Resident #1's RP before administering Trazodone. 2. The facility failed to respond to the pharmacist's notification that Resident #2's Lorazepam (a medication used to treat anxiety) consent was missing and needed to be obtained and uploaded. The facility had an unsigned written consent from Resident #2's RP before administering Lorazepam. This failure could place residents at risk of not having their preferred RP represent them in medical and care decisions, their preferred RP being unaware of the care, treatment, and treatment alternatives they are being provided, and not having pharmacist's notifications and recommendations for their medications and treatments followed. Findings included: Resident #1 Review of Resident #1's admission record, dated 09/19/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE], had a POA/RP , and with diagnoses including burns involving 20-29% of body surface with 0%-9% third degree burns, bipolar disorder current episode depressed mild or moderate severity unspecified, generalized anxiety disorder, and cognitive communication deficit. Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 3, indicating she had severe cognitive impairment. Section N (Medications) reflected Resident #1 was receiving an antipsychotic and antidepressant. Review of Resident #1's quarterly care plan, dated 08/19/24, reflected she had a mood problem related to bipolar disorder, anxiety, and history of alcohol abuse with an intervention to monitor, record, and/or report to MD as needed any signs or symptoms of depression, anxiety, or sad mood. Resident #1's care plan also reflected she used antipsychotic medications (Seroquel) related to bipolar disorder with an intervention to monitor/document/report as needed any adverse reactions of antipsychotic medications, such as insomnia. Page 1 of 3 675956 675956 09/19/2024 Windsor Nursing and Rehabilitation Center of Duval 5301 W Duval Rd Austin, TX 78727

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's order summary report, dated 09/19/24, reflected an active order started on 06/10/24 for the following: Trazodone HCI Oral Tablet 50 MG (Trazodone HCI) Give 0.5 tablet by mouth at bedtime for insomnia (give 25mg). Review of Resident #1's electronic health records, as of 09/19/24, reflected there was no consent form for her Trazodone HCI Oral Tablet 50 MG (Trazodone HCI) order. Review of Resident #1's MAR schedule for August and September 2024 reflected she received the Trazodone order from 08/01/24 through 09/18/24 . Resident #2 Review of Resident #2's admission record, dated 09/19/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE], had an RP, and with diagnoses including paranoid schizophrenia and unspecified dementia. Review of Resident #2's quarterly MDS, dated [DATE], reflected no BIMS score indicated. Section N (Medications) reflected Resident #1 was receiving an antidepressant. Review of Resident #2's quarterly care plan, dated 08/27/24, reflected she had the potential to be verbally aggressive related to dementia and mental/emotional illness. Review of Resident #2's order summary report, dated 09/19/24, reflected she completed the following order started on 08/22/24 and ended on 09/05/24: Lorazepam (Ativan) 0.5MG/ML GEL 0.5 mg/1ml MG/ML (Lorazepam) Apply 0.5 mg transdermally every 8 hours as needed for anxiety/agitation for 14 Days. Review of Resident #2's Informed Consent for Psychoactive Medications, undated, reflected an order for Lorazepam Gel for acute agitation and anxiety. Resident #2 printed her name on the consent 08/22/24 and did not sign. RP printed their name on 08/22/24 and did not sign. Facility representative who provided information and completed the consent form signed on 08/22/24 . Review of Resident #2's MAR schedule for August and September 2024 reflected she did not receive the Lorazepam order from 08/01/24 through 09/18/24 . Review of the facility's Pharmacist Review from June through August 2024 reflected the Pharmacist initiated a medication regimen review on 06/17/24 and indicated Resident #1's Trazodone consent was unable to be located and recommended staff to obtain and scan consent into the chart. The Pharmacist also initiated a medication regimen review on 08/26/24 and indicated Resident #2's Lorazepam consent was unable to be located and recommended staff to obtain and scan consent into the chart. During an interview on 09/19/24 at 1:23 p.m., the NP stated consents must be signed by residents' POAs . During an interview on 09/19/24 at 2:39 p.m., the ADON stated her expectations for psychological consents were that they were to be signed right away from pen to paper. The ADON stated consents must be signed by the resident or the resident's RP. The ADON stated it was important to have consents signed so staff had consent to treat the resident using medications. The ADON stated the receiving 675956 Page 2 of 3 675956 09/19/2024 Windsor Nursing and Rehabilitation Center of Duval 5301 W Duval Rd Austin, TX 78727

F 0756 Level of Harm - Minimal harm or potential for actual harm nurse was responsible for getting residents' consents signed. The ADON stated her, and the DON's job were to oversee and make sure residents' consents were completed . Review of the facility's Notification of Changes policy and procedure, implemented 10/24/22, reflected the following: Residents Affected - Few The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. Additional considerations: 2. Residents incapable of making decisions: a. The representative would make any decisions that have to be made. b. The resident should still be told what is happening go him or her. 675956 Page 3 of 3