Health inspection·February 14, 2023

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. Based on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 3 of 12 months (October 2022, November 2022, December 2022) reviewed for pharmacy services. The facility did not have a licensed pharmacist and witnesses initial or sign the attached pages of medication destruction inventory sheets. This failure could put residents at risk for misappropriation and drug diversion. Findings: During a record review of facility drug destruction log, the drug destructions dated, 10/11/2022, 11/8/2022, and 12/8/2022 indicated attached pages of medication destruction contained photocopied printed names of DON and Administrator but did not include the actual signatures of DON and Administrator. The Narcotic destruction log dated 11/8/22 only contained the signature of the consultant pharmacist, and no other witness signatures. During an interview on 2/14/23 at 1:01 PM, the DON stated she oversaw the facility drug destructions and was not sure how those pages got missed, but that they normally were always signed or initialed. The DON said the risk of not accounting and destroying medications per regulation could be a drug diversion. The DON stated going forward the facility would follow the regulation and reconcile the medications with initials or signatures to each inventory sheet as regulated. During an interview on 2/14/23 at 1:02 PM Admin said that the DON was ultimately responsible for drug destruction and that she always signed the sheets when the DON brought them to her after quarterly destruction. The Admin said the risk could include a drug diversion if medications are not destroyed and appropriately accounted for. Record review of facility policy and procedure titled, Drug Destruction Policy dated 7/10/2013 indicated, .9. Record retention. The consultant pharmacist and facility will maintain destruction record for two (2) years from the date of the destruction and will include the following information: date of destruction, name and address of dispensing pharmacy, prescription number if available, name of resident, name, strength and quantity of the drug, and signature of consultant pharmacist and witness of destruction (DON, ADON or Administrator). Page 1 of 5 675960 675960 02/14/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of 22 TAC §303.1 Destruction of Dispensed Drugs accessed online 2/14/2023 at https://texreg.sos.state.tx.us/ indicated; (a) Drugs dispensed to patients in health care facilities or institutions. (1) Destruction by the consultant pharmacist. The consultant pharmacist, if in good standing with the Texas State Board of Pharmacy, is authorized to destroy dangerous drugs dispensed to patients in health care facilities or institutions. A consultant pharmacist may destroy controlled substances as allowed to do so by federal laws or rules of the Drug Enforcement Administration. Dangerous drugs may be destroyed provided the following conditions are met. (A) A written agreement exists between the facility and the consultant pharmacist. (B) The drugs are inventoried, and such inventory is verified by the consultant pharmacist. The following information shall be included on this inventory: (i) name and address of the facility or institution. (ii) name and pharmacist license number of the consultant pharmacist. (iii) date of drug destruction. (iv) date the prescription was dispensed; (v) unique identification number assigned to the prescription by the pharmacy; (vi) name of dispensing pharmacy; (vii) name, strength, and quantity of drug; (viii) signature of consultant pharmacist destroying drugs; (ix) signature of the witness(es); and (x) method of destruction. C) The signature of the consultant pharmacist and witness(es) to the destruction and the method of destruction specified in subparagraph (B) of this paragraph may be on a cover sheet attached to the inventory and not on each individual inventory sheet, provided the cover sheet contains a statement indicating the number of inventory pages that are attached and each of the attached pages are initialed by the consultant pharmacist and witness(es). v) any two individuals working in the following capacities at the facility: (I) facility administrator; (II) director of nursing; (III) acting director of nursing; or 675960 Page 2 of 5 675960 02/14/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0755 (IV) licensed nurse. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675960 Page 3 of 5 675960 02/14/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents reviewed for infection control. (Resident #35) Residents Affected - Few NA A did not wash or sanitize their hands when changing gloves while performing incontinent care for Resident #35. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of a face sheet for Resident #35 dated 2/14/2023 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (memory loss), dysphagia (difficulty speaking), lumbago with sciatica (pain that goes from the lower back into the legs and feet) and hypertension (high blood pressure). Record review of a care plan for Resident #35 with a revision date of 9/15/2021 indicated she had bladder and bowel incontinence with interventions to provide incontinent care at least every 2 hours. Record review of a Significant MDS assessment dated [DATE] for Resident #35 indicated she was rarely/never understood. She required extensive assistance with one to two person assist with ADL's. She was always incontinent of bladder and bowel. During an observation on 2/13/2023 at 10:40 AM, NA A was in Resident # 35's room to provide incontinent care. NA A washed her hands prior to providing care in the resident's bathroom. She removed wipes from the container and pulled brief down between Resident #35's legs. NA A wiped Resident #35's perineal area from front to back and rolled her to her right side. NA A removed her gloves and placed them in the trash. NA A placed gloves on both hands without washing or sanitizing them and removed a wipe from the container and wiped Resident #35's rectal area from front to back. NA A removed the brief and placed in it in the trash. NA A placed a clean brief under Resident #35's buttocks and rolled her onto her back and secured the brief. NA A removed the gloves and placed them in the trash. During an interview on 2/13/2023 at 10:45 AM, NA A said she had been employed at the facility for a year. She said when providing incontinent care to Resident #35, she should have washed or sanitized her hands between glove changes. She said she received training on incontinent care and hand hygiene initially on hire. She said a resident could get an infection if staff did not wash or sanitize their hands when changing gloves. Record review of a facility in-service dated 1/9/2023 indicated staff were trained on handwashing, infection control and ABHS usage. NA A was in attendance as indicated by her signature on the attendance roster. Record review of a CNA proficiency audit for NA A dated 3/31/2022 indicated she received satisfactory on perineal care and proper handwashing skills check off. 675960 Page 4 of 5 675960 02/14/2023 Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/13/2023 at 1:25 PM, the DON said collectively herself and both ADON B and ADON C were all responsible for making sure staff received training and proficiency in incontinent care and hand hygiene. The DON said they check annually for proficiency with skills checkoffs and if they had issues with any staff member, they would provide staff more training. The DON said NA A would receive more training on incontinent care and hand hygiene. The DON said she would provide a general refresher with all staff. The DON said NA A was not certified yet, but she had completed all her training hours and had taken her test, but the facility had not received her NA number yet. The DON said an in-service was conducted at the facility on 1/9/2023 on handwashing, infection control and hand sanitizer usage. The DON said NA A was in attendance. Record review of a facility policy and procedure manual updated 3/2022 titled Fundamentals of Infection Control Precautions indicated, .The facility will establish and maintain, and Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. 1. Hand Hygiene continues to be the primary means of preventing the transmission of infection: when coming on duty, after removing gloves, and after completing duty . 675960 Page 5 of 5