Health inspection·February 8, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program to the maximum extent practicable for 1 of 5 residents (Resident #17) reviewed for PASARR. Residents Affected - Few The facility failed to update the PASARR Level 1 forms for Resident #17 to indicate mental health illness. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings included: Record review of Resident #17's admission Record, dated 12/28/2023, revealed an 84 -year-old male who admitted to the facility on [DATE]. Resident # 17 face sheet dated 02/08/2024 revealed that Resident # 17 had an active diagnosis of (PTSD) Post Traumatic Stress Disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations.) with an onset documented as of 12/28/2023. Record review of Resident #17 clinical record, Resident #17 was diagnosed with Post Traumatic Stress Disorder (PTSD) with an onset documented as of 12/28/2024. PASRR Level 1 Screening for Resident #17 dated for 12/28/2023 indicated incorrect documentation of no mental health illness. As result of the incorrect documentation, it was determined that resident was not eligible for PASRR specialized services. Record review of Resident #17's care plan dated 12/28/2023 read in part Resident #17 uses psychotropic medications related to insomnia and anxiety but did not make mention of Post Traumatic Stress Disorder (PTSD). Interview on 02/06/24 at 10:43 am, Resident #17 stated that he often becomes anxious with staff as he felt that staff does not understand him. Resident #17 stated that he was abused as a child and as an adult he served in Navy. Resident #17 revealed that he often has trouble sleeping at night. He stated that he received his medications but did not know what medications he had been taking. Resident #17 denied receiving any services and support related to coping with PTSD and anxiety. Interview with MDS Coordinator on 02/06/24 at 11:56 AM revealed she had worked at the facility as an MDS Coordinator since December/2023. MDS Coordinator revealed that she was not aware why an Page 1 of 7 676170 676170 02/08/2024 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few updated PASRR Level I had not been completed for Resident #17 after identifying that Resident #17 was diagnosed with PTSD with an onset documented as of 12/28/2023. Interview with MDS Coordinator on 02/07/24 at 2:00 PM revealed that she was responsible for completing the PASRR. She stated that she completed a PASSR Level 1 referral update on 02/07/2024 after surveyors' interview on 02/06/2024. She confirmed that Resident #17's PASSR Level 1 on admission was negative and he was diagnosed with PTSD with an onset documented as of 12/28/2023. MDS Coordinator stated that she did not know that she had to submit an updated PASSR Level 1 indicating that Resident #17 had an active diagnosis of PTSD. The MDS Coordinator did not state whether she had received any training regarding PASSR . MDS Coordinator did not reveal how monitoring was conducted to ensure it was done timely and accurately. She did not know why the referral had not been completed on 12/28/23 and she said that it would be important for a resident to receive PASARR services if they qualified. The MDS Coordinator said that the potential risk to a resident for not having the corrected referral submitted to identify mental health illness, would be that the resident would not receive the necessary services qualified for. Record review of the facility's Resident Assessment-Coordination with PASARR Program policy dated implemented 6/2023 and Date Revised: 06/2023 revealed 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .b. A resident whose intellectual disability or related was not previously identified and evaluated through PASARR. 676170 Page 2 of 7 676170 02/08/2024 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure residents maintained acceptable parameters of nutritional status, such as usual body weight for 1 of 5 residents (Residents #31) reviewed for nutrition. Residents Affected - Few - The facility failed to ensure the implementation of the Registered Dietitian's recommendations that included Fortified meals for Resident #31. This failure could place residents at risk for weight loss and decline in health status. Findings include: Record review of Resident #31's Face Sheet dated 02/06/24 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: Alzheimer's Disease, and hypertension. Record review of Resident #31's MDS assessment dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 01 out of 15, no malnutrition, no specified therapeutic diet, and set-up and clean up assistance for eating. Record review of Resident #31's undated Care Plan revealed, no weight related care areas. Record review of Resident #31's weight dated 01/08/24 revealed, 89.8 lbs. Record review of Resident #31's Diet Requisition Form dated 01/08/24 revealed, the resident was on a regular diet. Record review of Resident #31's weight dated 01/17/24 revealed, 90.0 lbs. Record review of Resident #31's Nutrition/Dietary Note dated 01/22/24 at 11:16 AM revealed, Resident #31 was 90.5 lbs. with a BMI was 16.6 (underweight) and her ideal body weight was 136-147 lbs. Oral intake likely adequate to meet estimated nutritional needs; however resident BMI indicates she is underweight. Resident may benefit from fortified food plan to promote weight gain. Goals:1. Gradual weight gain with a BMI goal >20; 2. Maintain adequate oral intake and start fortified food plan, all meals, indefinitely. Record review of Resident #31's weight dated 01/23/24 revealed, 90.5 lbs. Record review of an email dated 01/25/24 at 08:00 AM revealed, an email from the dietician that read Attached are the recommendations from my last visit. I will be returning on Friday of this week. The email had Resident #31's dietary recommendation of start fortified food plan, all meals, indefinitely and it was addressed to the facility CEO, Administrator, DON, ADON and Unit Manager A. Record review of Resident #31's Order Summary Report dated 02/07/24 at 01:58 PM revealed, no entered orders for a fortified diet. Record review of Resident #31's Meal Tickets and Diet Requisition Form presented on 02/07/24 at 03:11 PM revealed, the resident was ordered and received a regular diet. She was not ordered or 676170 Page 3 of 7 676170 02/08/2024 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0692 receiving fortified meals. Level of Harm - Minimal harm or potential for actual harm An observation on 02/06/24 at 10:24 AM revealed, Resident #31 well dressed and in no immediate distress in her room. The resident appeared thin but not frail and confused. Resident #31 was unable to answer the surveyor's questions. Residents Affected - Few In an interview on 02/07/24 at 02:50 PM, the ADON said after her weekly visit the dietician emails her recommendations and these recommendations are forwarded to the unit managers for order entry and implementation. She said if a resident had a dietary recommendation for fortified meals there should be a corresponding order entered. After reviewing Resident #31's EMR the ADON said there was no order for fortified meals entered for Resident #31. The ADON said the nurse managers are responsible for ensuring dietary orders are entered and implemented accurately. In an interview on 02/07/24 at 03:11 PM, Dietary Staff A said the dietician communicated her recommendations to the nursing team who then enter the orders into the system and sometime the nurse manager will deliver the orders to her for implementation. She said dietary recommendations are usually entered with 24 hours and then implemented on the next meal ticket. Dietary Staff A said Resident #31 did not have an order for fortified meals and the resident had the same ordered regular diet since admission on [DATE]. In an observation and interview on 02/08/24 at 09:37 AM, Nurse Manager A said she was the nurse responsible for entering dietary orders for Resident #31's unit and residents are seen by the dietician weekly and new dietary orders are normally implemented within 24 hours. She said after the dietician sees a resident, she sends an email to nursing administration and the nurse manager is responsible for transcribing the new dietary orders into the system. Nurse Manager A said once the order is entered the nurse will print out the order and physically deliver it to the dietary department. She said she kept a binder of all new dietary orders that she signed off on once she implemented them. Observation of the binder revealed a print out on 01/24/24 with the dietician's orders. There were 5 resident names highlighted, including Resident #31, and all resident names had a check beside their orders except for Resident #31. Unit Manager A said she did not know why she failed to enter and implement Resident #31's new dietary orders and failure to implement dietary recommendations as orders could place residents at risk for untreated weight issues or weight loss. On 02/08/24 at 09:58 AM, an attempt was made to contact the dietician. A voicemail was left, but the dietician did not return the call prior to exit. Record review of the facility policy titled Dietary Services, Certified Dietician revised 09/2022 revealed, 1the certified dietician must conduct assessments of residents to ensure proper intake; 3- the certified dietician must issues recommendations that will be reviewed by physician for approval then transcribed into the EMR and implemented by dietary services. 676170 Page 4 of 7 676170 02/08/2024 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

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 observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs for 1 of 4 medication Carts (Station 1 PRN Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure the Station 1 PRN nursing cart did not contain an expired bottle of Vitamin C 250 mg. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings Included: In an observation on 02/08/24 at 07:10 AM, inventory of the Station 1 PRN Nursing Cart with LVN A revealed: - An expired, open and in use stock bottle of Vitamin C 250 mg with a manufacturer's expiration date of 01/2024. LVN A said nursing staff are expected to check their medication carts daily for expired medications as they use the medications and then weekly. She said when supplements expire they might be less effective so they should be discarded because use could result in adverse reactions and under supplementation. In an interview on 02/08/24 at 07:40 AM, the DON said nursing staff are expected to check their carts daily as medication is used for inappropriately labeled and expired medications, while nursing management/unit managers also audit the carts once a week and randomly. He said expired medications must be removed and placed in the drug disposal bin in the medication room because it could result in adverse reactions. Record review of the facility policy titled Medication Administration revised 08/2022 revealed, 14. All multi-use containers must be labeled with opening date. If container is found to be opened and not labeled, it must be discarded. 15. All medication on the medication cart must be audited as needed, and any unlabeled, loose or expired medications must be removed and placed in medication destruction. 16. All expired and discontinued medications are reviewed and destroyed monthly by the pharmacy consultant. 676170 Page 5 of 7 676170 02/08/2024 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and under proper temperature controls for 1 out of 8 Residents (Resident #43) and 1 of 4 medication carts ( Station 3 Medication Cart) reviewed for drug labeling and storage. - The facility failed to ensure the Station 3 Medication Cart did not contain an in-use insulin pen for Resident #43 with no open date. This failure could place residents at risk of adverse medication reactions and drug diversions. Findings included: Record review of Resident #43's Face Sheet dated 02/06/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of anxiety disorder, high cholesterol and type 2 diabetes. Record review of Resident #43's Quarterly MDS assessment dated [DATE] revealed, intact cognition as indicated by a BIMS of 14 out of 15, partial/moderate assistance with most ADLs and always continent of both bladder and bowel. Record review of Resident #43's undated Care Plan revealed, focus- resident has diabetes and requires insulin; intervention- diabetes medication as ordered by doctor. Record review of Resident #43's Order Summary Report dated 02/08/24 revealed, HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 69 = 0; 70 - 99 = 20; 100 - 150 = 30; 151 - 200 = 40; 201 - 250 = 50; 251 - 300 = 60; 301 - 350 = 70; 351 - 400 = 80 Above 400 call MD, subcutaneously three times a day for diabetes. In an observation on 02/08/24 at 07:27 AM, inventory of the Station 3 Medication Cart with LVN B revealed: - An open and in-use Insulin Lispro Pen for Resident #43 with no open date. LVN B said nursing staff are expected to check their carts daily as medications are used for inappropriately labeled medications. She said insulin pens must be labeled with the date opened in order to track the expiration date. LVN B said when insulin expires it can not be used and must be discarded in the drug disposal bin. She said since the insulin pen did not have an open date it should not be used because it could be expired and if used it could result in uncontrolled blood sugars. In an interview on 02/08/24 at 07:40 AM, the DON said nursing staff are expected to check their carts daily as medication is used for inappropriately labeled and expired medications, while nursing management/unit managers also audited the carts once a week and randomly. The DON said all multidose 676170 Page 6 of 7 676170 02/08/2024 St Dominic Village Rehabilitation and Nursing Cent 2409 E Holcolm Blvd Houston, TX 77021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insulin pens/containers must be labeled with the date open/removed from the refrigerator in order to track the expiration. He said when insulin expired it could become unstable and less effective and use can result in uncontrolled/ineffective control of blood sugars. The DON said if an insulin pen did not have an open date it cannot be used and must be discarded in the drug disposal bins located in the medication room. Record review of the facility policy titled Medication Administration revised 08/2022 revealed, 14. All multi-use containers must be labeled with opening date. If container is found to be opened and not labeled, it must be discarded. 15.All medication on the medication cart must be audited as needed, and any unlabeled, loose or expired medications must be removed and placed in medication destruction. 16. All expired and discontinued medications are reviewed and destroyed monthly by the pharmacy consultant. 676170 Page 7 of 7