Health inspection·March 21, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 2 of 22 residents (Residents #48 and #56) reviewed for care plans as follows: Facility failed to develop a care plan for Residents #48 and #56 for current advanced directives. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #48 Record review of the admission record for Resident #48, dated 03/20/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: essential hypertension (high blood pressure), mild protein-calorie malnutrition (poor food intake) and muscle weakness. Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #48 was understood and had a BIMS score of 10 indicating that the resident's cognition was moderately impaired. Record review of the order summary report for Resident #48, dated 03/20/24, revealed there were orders for Do Not Resuscitate (DNR) consent on file with a start date of 02/06/24. Record review of the current care plan for Resident #48, undated, revealed there was a focus area: [Resident #48] has an Advanced Directive and has documentation in their medical record r/t Code status: Full Code; Goal: [Resident #48's] wishes will be honored and maintained through next review date; Interventions/Tasks: Honor the resident choice for code status Resident #56 Record review of the admission record for Resident #56, dated 03/20/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: unspecified severe protein-calorie malnutrition (poor food intake), cerebral infarction (stroke), and dysphagia (difficulty swallowing). Page 1 of 4 675997 675997 03/21/2024 Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #56 was usually understood and had a BIMS score of 10 indicating that the resident's cognition was moderately impaired. Record review of the order summary report for Resident #56, dated 03/20/24, revealed the following order: Do No Resuscitate (DNR) with a start date of 05/02/23. Record review of the current care plan for Resident #56, undated, revealed there was no specific care plan regarding advanced directives. During an interview on 03/21/24 at 9:48 AM, SW A and SW B stated they were both responsible for ensuring the resident's current advanced directives are in the care plan. SW A and SW B stated they were unsure why Resident #48 and Resident #56 did not have their current advanced directives care planned. SW A and SW B stated the care plans are reviewed every 3 months for accuracy and these care areas must have been missed. SW A and SW B stated the potential negative outcome to the residents was they were at risk for not having their wishes met. During an interview on 03/21/24 at 10:01 AM, the ADM stated the social workers and the MDS nurses are responsible for ensuring all care areas for residents are in the care plan. The ADM stated she did not know why Resident #48 and Resident #56 did not have a current care plan for their advance directives. The ADM stated the social workers are trained to ensure the advanced directives are care planned. The ADM stated the potential negative outcome to the residents was the staff may not follow the residents wishes. Record review of the facility policy titled, Resident Care Plans, undated, reflected the following: Standard: An individualized interdisciplinary plan of care will be developed for each resident. Purpose: To assist the resident in achieving his or her optimal level of functioning consistent with the physician's plan of medical care. Guideline: 1. Assessment data is collected for analysis and integration to identify and prioritize each resident's care needs. Advanced directives are considered during this process 675997 Page 2 of 4 675997 03/21/2024 Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that 1 of 22 residents (Resident #34) reviewed for PRN psychotropic medications. Resident #34 continued to have a PRN order for Lorazepam 0.5mg after 14 days without a duration. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions. The findings include: Resident #34 Record review of Resident #34's face sheet, dated 03/19/24, reflected a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include colon cancer, major depressive disorder (mental illness), and anxiety (feeling of fear and worry). Record review of Resident #34's quarterly MDS, dated [DATE], reflected Resident #34's BIMS was a 10 which indicated Resident #34 had moderate cognitive impairment. The MDS further reflected Resident #34 had a diagnosis of anxiety disorder and was taking antianxiety medication. Record review of Resident #34 care plan dated 01/12/24 reflected a care plan related to anxiety and Lorazepam medication. Interventions to administer medications, assist with positive coping skills, encourage resident to express feeling and monitor/document mood. Record review of Resident #34's physician order summary dated 03/19/24 reflected an order start date 10/22/23 with an indefinite end date for Lorazepam Intensol Oral Concentrate 2 mg/ml, give 0.25 ml by mouth every 1 hours as needed for anxiety and restlessness related to malignant neoplasm of colon. Record review of Resident #34's PRN MAR dated 03/19/24 reflected Lorazepam Intensol Oral Concentrate 2 mg/ml give 0.25 ml by mouth every 1 hours as needed for anxiety and restlessness related to malignant neoplasm of colon. Start Date 10/22/23 - open ended. No medication was administered for the month of March. Record review of Resident #34's pharmacy review titled Note to attending physician/prescriber dated 02/06/24 reflected Resident #34 was receiving lorazepam Intensol 0.5 mg (0.25ml) every 1 hours PRN anxiety and restlessness and order began on 10/22/23. Physician response - Anxiety tx - used PRN for comfort. Reassess in 6 months. During an interview on 03/20/24 at 03:45 PM with the DON, she stated Resident #34 had an order for Lorazepam PRN with no duration. She stated PRN psychotropic medications must have a stop dated and can only be given for 14 days. She stated lorazepam was a psychotropic medication. She stated she was 675997 Page 3 of 4 675997 03/21/2024 Carillon Inc 1717 A Norfolk Ave Lubbock, TX 79416

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsible for monitoring PRN psychotropic orders for stop dates. She stated the reason why Resident #34 does not have a stop date was because she thought the pharmacy review done on 2/6/24 was sufficient. She stated the order was not changed to include a duration. She stated the physician stated he would reassess Resident #34 in 6 months. She stated she had been trained on PRN psychotropic medications. She stated psychotropic medication monitoring was important to ensure residents were not being given unnecessary medications, not being used as a restraint and to make sure residents have the proper diagnosis. She stated the potential negative outcome could be resident declining and interfering with ADL's and resident being over medicated. During an interview on 03/21/24 at 09:35 AM with RN A, she stated PRN psychotropic medications were to have a 14 day stop date. She stated the reason Resident #34 lorazepam did not have a stop date was because the pharmacy recommendation state he would revaluate in 6 months. She stated there was no new order to change or add a duration. She stated Resident #34's lorazepam order did not have a duration or stop date. She stated she had been trained on PRN psychotropic medications. She stated the potential negative outcome could be overuse of medications or used as a chemical restraint. She stated monitoring and revaluation was necessary to ensure the medication was medically necessary and to make sure the resident was not over medicated. During an interview on 03/21/24 at 09:45 AM with ADM, she stated the DON was responsible for monitoring PRN psychotropic for proper documentation and duration. She stated monitoring PRN psychotropic medications was important to ensue residents need the medication and were not overmedicated. She stated all nurses have been trained on PRN psychotropic medications. She stated the potential negative outcome could be residents being over medicated. Record review of the facility policy titled Psychotropic Medication Use dated July 2022 reflected the following: Policy Statement: Resident will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation . 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend· the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order . 675997 Page 4 of 4