Health inspection·November 13, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 1 of 5 staff (LVN A) reviewed for abuse/neglect. Residents Affected - Few The facility failed to intervene when LVN A exhibited signs of impairment, admitted to being impaired, and was allowed to work her scheduled shift. This failure could place residents at risk of abuse and neglect. Findings included: Record review of explanation of separation for LVN A revealed: On February 6, 2023, LVN A was suspended pending investigation due to discrepancies in the narcotics count and failure to follow proper end of shift report. The facility's investigation indicated that LVN A had a total of 16 errors on the narcotic count sheets. Multiple discrepancies on the narcotic sheets were listed as wasted, error, or crossed out. In addition, four (4) Tramadol were unaccounted for, and several medications were not administered on the EMAR. LVN A admitted to being impaired during her shift due to taking too many prescription medications. She further admitted that this contributed to the errors in counting and missing medication. LVN A exhibited a disregard for the welfare of the facility's residents when she came to work impaired. As result, her employment will be terminated immediately. During an interview on 11/7/23 at 11:08 AM, LVN A said the morning of 2/7/23 she had accidently taken her night medication that morning. She said she had told the Previous Administrator and the DON she had mixed up her personal medications and had taken Seroquel and Trazadone that morning. She said she told the Previous Administrator that she was tired and groggy but neither the DON nor Previous Administrator offered a solution. She said that morning she told the DON and Previous Administrator to let her see how she felt but said no one asked her if she felt like she needed to go home. She said she felt like she was not in the right state of mind that day. LVN A said she was not drug tested that day. She said her coworkers had noticed she was not acting normally and had asked her if she was okay. LVN A said the treatment nurse also questioned her and she told her she had taken her night medications that morning. She said when LVN B came in at around 6 PM she was counting the narcotics with her and there was a discrepancy and LVN B would not continue counting with her. LVN A said she thought she only made one medication discrepancy on that day that was not accounted for. She said she does not know what happened to the medications. LVN A said she came in a couple of days later and went over the count sheets and said it looked bad but could not come up with an explanation other than she must have made a medication error. Page 1 of 7 676051 676051 11/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/7/23 at 11:30 AM, the Previous Administrator said an employee reported to him and the DON that LVN A was acting off . He said at around noon he stood at the nurse's station and monitored LVN A for about 15 minutes. He said LVN A was resting her head on her hands but other than that LVN A seemed fine. He said LVN A told him she took her medication the night before and could not sleep and was up all night. The Previous Administrator said during his observation LVN A only seemed tired. He said he asked LVN A if she was okay or had anything going on and she told him she was fine that she was just tired. He said LVN A was not drug tested at that time. The Previous Administrator said the DON spoke with LVN A by phone the next day and told LVN A she needed to return to the facility and give a statement. The Previous Administrator said the DON told LVN A on more than one occasion that she needed to return to the facility to give a statement. He said LVN A did not return to the facility when asked to but did come to the facility sometime within the next week. The Previous Administrator said he could not remember if LVN A was terminated or if she just never returned to work. During an interview on 11/7/23 at 11:39 AM the Treatment Nurse said she witnessed the incident around 6 pm on 2/7/23 between LVN A and LVN B. The Treatment Nurse said LVN A appeared to be high but said she did not know if she was high or tired. She said LVN A fell on the floor while LVN B was there. The Treatment Nurse said she had asked LVN A all that day what was wrong with her because she was not acting right and had fallen asleep at the desk. She said she had seen a medication bottle with LVN A's name, that was labeled Clonazepam and that LVN A had told her she takes 2-3 Clonazepam at night and did not know if that was what was wrong with LVN A. The Treatment Nurse said she had reported it to the Previous Administrator, and she had seen him observing LVN A. She said the Previous Administrator always left at 4pm so he would have to have been observing LVN A before that. The Treatment Nurse said when LVN A fell asleep at the desk the Previous Administrator was watching LVN A. She said it was towards the end of her shift is when she felt like LVN A was not safe. The Treatment Nurse said she had never seen LVN A take any medications at work or take any medications from the residents. The Treatment Nurse said LVN B said she was not going to take possession of the medication cart because the narcotic count was wrong, and she was calling the DON to come and reconcile the cart. The Treatment Nurse said she did not know what happened after that. The Treatment Nurse said she did not see LVN A working at the facility anymore after that night. The Treatment Nurse said she did see LVN A at the facility a few days later and LVN A told her she had come back to write a statement. During an interview on 11/7/23 at 12:15 PM, the DON said that it was possibly the BOM that reported it to her that LVN A was not acting right. The DON said that she spoke with LVN A and LVN A told her that she felt a little off, she was a little groggy and that she just was not as perky but that she was fine. The DON said every time she saw LVN A that day that she was acting appropriately. She said she never felt like LVN A was not safe or competent to complete her shift. The DON said that LVN A was responsible for 13 residents that day. During an interview on 11/7/23 at 2:46 PM the BOM said she had a concern that LVN A was talking to her and did not seem like herself . She said she felt like LVN A was off and reported it to the DON and Previous Administrator that day. The BOM said LVN A came to her office and LVN A had slurred speech and she could not complete her thought processes. She said LVN A seemed to be really tired, and her speech was off. She said if she is remembering correctly, it was maybe after the morning meeting but before lunch when the Previous Administrator monitored LVN A. She said she had never seen LVN A act like that before. The BOM said she did not see LVN A fall or fall asleep at the nurse's station that day. During an interview on 11/8/23 at 9:06 AM, LVN B said came into the facility for the night shift . 676051 Page 2 of 7 676051 11/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She said she began to get report from LVN A and count the narcotics on the medication cart. LVN B said as they were counting the cart almost all the narcotic counts were not right. LVN B said she stopped counting and called the DON to notify her that the counts were not right. LVN B said LVN A became upset and said she was not staying at the facility until the DON arrived and threw the keys to the medication cart down and left the facility. She said LVN A was visibly high and staggering that night. She said that she had never seen her like she was that day. She said the DON told her that it had been reported before , but no one ever wanted to write a statement so would she please write a statement. During an interview on 11/8/23 at 3:03 PM, LVN C said on the morning of 2/6/23 she and LVN A counted the narcotics on the medication cart and all counts were correct. She said that morning LVN A acted like she normally did, and she did not notice any abnormal behavior. She said that she had never witnessed LVN A where she felt like LVN A was unsafe to provide care for the residents. Record review of facility's policy undated titled Drug-Free Workplace Policy Acknowledgement Form revealed: The Company explicitly prohibits: 2. Being impaired or under the influence of legal or illegal drugs or alcohol while at work, or away from work, if such impairment or influence adversely affects the employee's work performance, the safety of the employee, their co-workers or of our residents, or puts at risk the Company's reputation. Signed by LVN A on 1/13/21. Record review of Consent to Drug and/or Alcohol Testing revealed: I hereby agree, upon a request made under the drug/alcohol testing policy of the Community, to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. Signed by LVN A on 1/4/2021. Record review of LVN A time sheet punch detail for 2/6/23 revealed: LVN A clocked into the time clock at 6:00 AM and clocked out at 7:01 PM indicating that LVN A worked 13:02 hours that day. Record review of the facility Abuse, Neglect, and Exploitation and Misappropriation of Resident Property policy dated June 23, 2017. The Purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and resident from abuse, neglect, exploitation and misappropriation of resident property, and (ii)timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property. 1. Resident Rights: Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of residents property, corporal pucishment, and involutary seclusion. Residents must not be subjected to abuse, neglect, exploitation, misappropriation of resident's property by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, resident representative, friends, or other individuals. Record review of the facility team member handbook indicated: Drug and Alcohol Testing: For Cause- The company may require a team member to undergo drug or alcohol testing if it reasonable believes that the employee may be under the influence of drugs or alcohol, including, but not limited to, the following circumstances: 2. Conduct on the team member's part suggests impairment or influence of drugs or alcohol; 3. A report of drug or alcohol use or impairment while at work or on duty. 676051 Page 3 of 7 676051 11/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

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 observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 27 residents (Resident #3 and Resident #13) and reviewed for pharmacy services. The facility failed to ensure Resident #3 took his medication on 10/17/23 resulting in Resident #3 selling his Hydrocodone to the Housekeeper. This did not result in any outcome for Resident #3. The facility did not ensure medications were properly administered to Resident #13 on 7/1/23. The ADON was not able to identify what medications had been administered to resident #13 on 2 separate occasions 21 minutes apart. This did not result in any outcome for Resident #13. These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and not receiving the intended therapeutic benefit of the medications. Findings included: 1.Record review of facility face sheet undated indicated Resident # 13 was an [AGE] year-old male admitted to facility on 08/26/2022 with diagnosis of acute kidney failure, and pneumonia (lung infection). Record Review of comprehensive care plan dated 11/9/2023 indicated Resident # 13 had Gout and to administer anti-inflammatory medications and other drugs as ordered, had pain and to administer pain medications as ordered. Care plan did not indicate Resident # 13 could safely self-administer medications. Record review of Quarterly MDS dated [DATE] indicated Resident #13 had a BIMS of 07 indicating severe cognitive impairment. Record review of physician orders dated 7/1/2023-7/31/23 indicated Resident #13 had an order for Calcium Acetate 667mg give 2 capsules by mouth three times daily at 8am 2pm and 8pm, Carvedilol 3.125mg give 1 tablet by mouth twice daily at 8am and 8pm, Doxycycline Hyclate 100mg give 1 capsule by mouth twice daily at 8am and 8pm, Gabapentin 100mg give 1 capsule by mouth three times daily at 8am 2pm and 8pm, Hydrocodone 5/325mg give 1 tablet by mouth twice daily at 8am and 8pm, [NAME]-Vite Rx 1mg-60mg-300mcg give 1 tablet three times daily at 8am 2pm and 8pm. During an observation of two videos provided by Resident #13's family member revealed on 7/1/23 at 11:26 PM ADON entered Resident #13's room, stirred a substance in a medication cup, gave the resident two bites with a spoon from the medication cup and then gave Resident #13 a drink out of a cup on the residents bedside table. On 7/1/23 at 11:47 PM ADON entered Resident #13's room carrying a medication cup and what appeared to be a glass of water, ADON poured what appeared to be medication into Resident #13's mouth and gave him a drink from what appeared to be a cup of water and exited the room. Record review of a written statement by the ADON dated 7/2/23 revealed: I ADON, RN worked 6-6 on 676051 Page 4 of 7 676051 11/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Saturday night. I have not been feeling well for over 3 weeks, was released Friday to come back to work. Worked Saturday night due to a call in. Gave meds until I got behind, the had help to get my 10pm meds passed out. There is a camera in 46. [Family member states I gave him crushed meds @11:27pm the came back and gave him meds at 11:48pm. I do not remember giving anyone on D Hall crushed meds. During an interview on 11/7/23 at 12:15 PM the DON said ADON called her crying after the incident and still did not remember what she had given resident. She said the corporate nurse handled the situation, but she did call to terminate ADON. The DON said the ADON told the corporate nurse that she had not been trained. During an interview on 11/7/23 at 12:37 PM the RNC said she received a call from the facility stating a residents' family member was upset that the ADON had given Resident #13 medication twice. RNC said she met Resident #13's family member at the facility. She said Resident #13's family member showed her a video that the ADON had medicated Resident #13 twice and did not want the ADON back in Resident #13's room. The RNC said Resident #13 was then transferred to the ER for evaluation and returned to the facility the same night with no new orders. She said she spoke with the ADON, and she did not recall giving him crushed medications or giving him medications twice. The RNC said the ADON told her that no one on the unit gets crushed medications so she did not think that she had given anyone crushed medications. The RNC said the ADON told her she had been out sick and was tired and not feeling well and she did not remember giving him medication, but guessed if it was on camera then she did. The RNC said the ADON was suspended pending investigation at that time and ultimately terminated. She said it was never determined what medication was given to Resident #13. During an interview on 11/9/23 at 3:52 PM, Resident #13's family member said ADON entered Resident #13's room and gave him what looked like medication crushed in a substance from a medication cup on 7/1/23 at 11:26 PM and said here you go medicina (Spanish word for medication). She said then ADON then entered Resident #13's room again at 11:48 PM and gave him medication again that was not crushed and said, here you go. Record review of facility record titled Competency Checklist- Skill/Procedure: Medication Administration dated 10/14/2022 revealed the ADON had Met performance criteria and was signed by the ADON and DON dated 5/24/23. Record review of facility record titled Nurse Skills Fair Competency Check-Off dated 4/12/2021 revealed the ADON had Pass skills competency for medication administration/enteral meds and was signed by the DON dated 5/19/23. Record review of facility record titled Notice of Warning dated 7/2/23 revealed the ADON was placed on investigatory suspension for the allegation of incorrect meds signed by the ADON and RNC on 7/2/23. 2. Record review of facility face sheet undated indicated Resident #3 was a [AGE] year-old male admitted to facility on 01/12/2023 with diagnosis of cerebral infarction (stroke), and myocardial infarction (heart attack). Record Review of comprehensive care plan dated 1/12/2023 indicated Resident #3 had an opioid and to administer Hydrocodone 10/325mg tablet administer one tablet by mouth every four hours as needed, had pain and to administer pain medications as ordered. Care plan did not indicate Resident # 13 676051 Page 5 of 7 676051 11/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0755 could safely self-administer medications. Level of Harm - Minimal harm or potential for actual harm Record review of comprehensive MDS dated [DATE] indicated Resident #3 had a BIMS of 09 indicating moderate cognitive impairment. Residents Affected - Few Record review of physician orders dated 10/1/23-10/31/23 indicated Resident #3 had an order for Hydrocodone 10/325mg give one tablet by mouth every four hours as needed for pain. Record review of a written statement given by Resident #3 to the DON dated 10/17/23, Interviewed resident and asked directly if he has ever sold medications or accepted medications not prescribed from staff or other residents. Resident states no I've never done that. Resident was informed that there was a situation that was witnessed, and the employee admitted to buying prescription Norco from this resident. Resident put his head down and continued to deny selling medication to staff member. After talking with resident, resident states that a few days ago like probably three days ago I did go up to someone and ask if they knew any one that would be interested in buying my pain meds. I asked resident who he approached. Resident states it doesn't matter, I'm not telling. I explained to resident it was important for us to know who he spoke with resident states I've said all I am going to say I'm not telling you who. Resident again denies the exchange of medication for money. I then asked resident how he would get medications to sell and he stated I was going to keep them when I get them. I then asked resident why he would do this. Resident states because I need the money. At this time I explained to resident that honesty was important and we needed to know if he has ever sold or accepted medications from staff outside of his medications received from nurse. Resident again states no I never have. Education provided to resident about importance of medication management and rules, resident verbalized understanding. The statement was signed by the DON and dated 10/17/23. Record review of a written statement dated 10/17/23 by the Housekeeper revealed: I was approached by Resident #3 and asked if I knew anyone that was interested in his pain meds and I said I'd get one since my back was truly hurting me after moving residents all day. I proceeded to get it and go back to work. I'm sorry for my poor decision making. I love [facility name] and I hope I can keep my position here. I'll never do it again. During an interview on 11/7/23 at 12:36 PM Resident #3 said he did not know what they are talking about he did not sell anyone any drugs. He said he did not sell the Hydrocodone to the Housekeeper but that he did talk to her about it. He said he knew the Housekeeper wanted the Hydrocodone because it had come up in conversation with her. During an interview on 11/8/23 at 11:49 AM, CNA D said she saw Resident #3 and the Housekeeper down the end of C hall talking and it looked a little sketchy , so she watched the exchange of money and pill. She said that Resident #3 rolled back up the hall with 20 dollars in his hand. She said she went to the Housekeeper and asked are you selling trying to get an answer out of her. She said the Housekeeper said no I bought something. She said the Housekeeper told her she sells Adderall outside of work. She said after that she went straight to the MDS nurse and reported it to her, and they reported it to the DON. Said the DON immediately went and got the Administrator and HR . During an interview on 11/8/23 at 12:10 PM, the MDS Nurse said CNA D came to her and said she needed to tell her something. The MDS Nurse said CNA D was worked up and told her she witnessed the Housekeeper get a pill from Resident #3. The MDS Nurse said the DON was passing by the door, and she told her she needed to come in and CNA D reported to the DON what she had witnessed. She said the DON went and got the Administrator and she did not know anything else. She said she never saw any other 676051 Page 6 of 7 676051 11/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0755 incidents like this. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/8/23 at 1:28 PM LVN E said she could not remember if she had given Resident #3 anything for pain on 10/17/23 . She said she did not see what happened between the Housekeeper and Resident #3 that day. She said that she has never left medications at a resident beside. She said that she will never ask a resident to open their mouth and let her see that the resident had swallowed their medication. She said she felt like it is violating the residents' rights to ask to see the inside of his mouth after taking medication. Residents Affected - Few During an interview on 11/8/23 at 4:20 PM, the DON said during medication administration the nurses are supposed to watch the resident and ask them if they had swallowed the medication. She said that in this setting you cannot ask the resident to open their mouth and move their tongue around. She said that it is not common practice to ask a resident to see inside their mouth. Record review of education provided to staff dated 10/17/23 by the DON, topic: When passing medication ensure resident is taking medication. Medication is not to be left for resident to take on their own time. Ensure all medication rights are followed. Ensure if PRN medication is administered that it is documented on the EMAR and the count sheet. Record review of education provided to staff dated 10/17/23 by the DON, topic: Misappropriation. Record review of facility documentation titled Notice of Warning dated 10/17/23, revealed Housekeeper was suspended placed on investigatory Suspension. Record review of email dated 10/18/23 at 1:51 AM to the facility Administrator from the local police department revealed the incident had been reported with case number 20230635. Record review of facility policy titled Medication Administration General Guidelines dated 01/23 revealed: Medications are administered as prescribed in accordance with manufacturers' specifications., good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. 5. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from prescriber. A. The need for crushing medications is indicated on the resident's orders and the MAR so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety and alternatives, if appropriate, during Medication Regimen Reviews. E. Medications which can be appropriately crushed may be ground coarsely and mixed with the appropriate vehicle (such as applesauce) so that the resident receives the entire dose ordered. Check dating of the mixing vehicle. 20. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. 676051 Page 7 of 7