Health inspection·April 26, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 12 residents (CR #1) reviewed for pharmacy services. - The facility failed to provide any medications via G-tube, a tube inserted through the belly that brings nutrition or medication directly to the stomach, to CR #1 for the duration of her stay from 04/12/23 to 04/13/23 This failure could place residents at risk of not having their diseases treated, adverse events and hospitalization. Findings Included: Record review of CR #1's Face Sheet dated 04/26/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: metabolic encephalopathy (chemical imbalance in the blood caused by organ malfunction that can lead to alteration in consciousness), difficulty swallowing, hypernatremia (high sodium in the blood), urinary retention and schizoaffective disorder ( mental health disorder with symptoms of both schizophrenia and mood disorder). She had no diagnosis of G-tube on her face sheet. CR #1 discharged from the facility on 04/13/23 at 05:30 PM due to the family not being satisfied with the services offered. Record review of CR #1's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 08 out of 15 and use of a walker. Record review of CR #1's EMR revealed, no documented care plan. Record review of CR #1's Hospital Discharge Instructions dated 04/12/23 at 11:10 AM revealed , the discharge instructions were signed by LVN A on 04/12/23 at 10:16 PM and indicated: - Fluoxetine 10 mg- 1 tablet daily next dose due on 04/13/23 in the AM. - Atorvastatin 10 mg- 1 tablet at bedtime; next dose due on 04/12/23 in the PM. - Benztropine 1 mg- 1 tablet 2 times daily; next dose due on 04/13/23 in the AM. - Donepezil 5 mg- 1 tablet at bedtime; next dose due on 04/12/23 in the PM. Page 1 of 3 676252 676252 04/26/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0755 - Haloperidol 5 mg- 1 tablet 2 times daily; next dose due on 04/13/23 in the AM. Level of Harm - Minimal harm or potential for actual harm - Metoprolol Tartrate 25 mg- 1 tablet daily; next dose due on 04/13/23 in the AM. - Ondansetron 4 mg- 1 tablet every 6 hours as needed for nausea and vomiting; next dose as needed. Residents Affected - Few - Pantoprazole 40 mg- 1 tablet daily; next dose due on 04/13/23 in the AM. Record review of CR #1's Physician's Orders dated 04/12/23 revealed: - Benztropine 1 mg- give 1 tablet via G-tube two times a day for tremors. - Fluoxetine 10 mg- give 1 tablet via G-tube, one time a day for depression - Haloperidol 5 mg- give 1 tablet via G-tube two times a day for agitation - Metoprolol Tartrate 25 mg (blood pressure medication)- 1 tablet by via G-tube one time a day. - Ondansetron 4 mg- give 1 tablet by via G-tube one time a day for nausea and vomiting. - Pantoprazole 40 mg- give 1 tablet via G-tube one time a day for GERD. - Donepezil (used to treat Alzheimer's disease) 5 mg- give 1 tablet via G-tube at bedtime. - Atorvastatin ( used to treat high cholesterol) 10 mg- 1 tablet at bedtime. Record review of CR #1's History and Physical dated 04/13/23 singed by the NP revealed, diagnoses, assessment and plan: Hyperlipidemia (high cholesterol)- continue Atorvastatin 10 mg daily at bedtime; Schizoaffective disorder- continue Haldol (Haloperidol), fluoxetine and Benztropine; Dementia- continue Aricept (Donepezil); hypertension (high blood pressure)- Metoprolol will be given; Nausea and Vomitingcontinue Zofran (Ondansetron) every 6 hours as needed; GERD- continue pantoprazole 40 mg daily. Record review of CR #1's MAR revealed, CR #1 did not receive any medications on the evening of 04/12/23 or throughout 04/13/23. Record review of the facility undated E-Kit (machine where medication is stored) Inventory revealed, the facility had Atorvastatin 10 mg, Benztropine 1 mg, Donepezil 5 mg, Fluoxetine 20 mg, Metoprolol Tartrate 25 mg and Ondansetron 4 mg available for administration to CR #1. In an interview on 04/26/23 at 01:55 PM, the DON said the admitting nurse LVN A was responsible for entering admission orders at the time of a new admission and since the EMR was linked to the pharmacy all knew orders are immediately sent to the pharmacy. She said the pharmacy delivers every day between 8:00-9:00 PM but medications can be retrieved from the E-Kit or from a local pharmacy prior to the daily delivery to ensure residents receive medications as ordered. The DON said per the facility MAR CR #1 did not receive any medications while she was a resident at the facility, and there were no medications pulled from the Exit for the resident. She said after reviewing CR #1's orders most of the resident's medications were available in the E-Kit and she did not know why the medication was not taken from the E-Kit. The DON said LVN A was the admitting nurse on 04/12/23 who entered CR 676252 Page 2 of 3 676252 04/26/2023 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1's orders, LVN B was the agency nurse on 04/13/23. She said all agency nurses are trained on orientation about the use of the E-Kit and she was never notified that CR #1 did not have any medications available for administration. The DON said if LVN B had informed her or the ADON about CR #1's unavailable medications the medication would have been retrieved from the E-Kit. The DON said nursing staff are expected to administer medications per the next scheduled dose instructions found on the hospital discharge instructions and failure to administer medications could place residents at risk of untreated health conditions and declining health. In an interview on 04/26/23 at 03:06 PM, LVN B said she was an agency nurse that took care of CR #1 on 04/13/23. She said she did not administer any medications to CR #1 on 04/13/23 because the resident's medications had not arrived from the pharmacy. LVN B said she had not been trained on retrieving medications from the E-Kit and had no access to medications in the E-Kit. She said she called the pharmacy to inform them that CR #1 was without medication but the pharmacy never got back to her. LVN B said she did not remember if she notified the DON/ADON or administrator about the missing medication because she was too busy completing her other tasks and then the resident discharged from the facility. LVNA said failure to administer residents medications places residents a risk of their disease states being untreated. In an interview on 04/26/23 at 03:20 PM, the DON said CR #1 did not have a completed baseline care plan or MDS because she was at the facility for less than 24 hours. An attempt was made on 04/26/23 at 03:05 PM to reach LVN A via telephone. Surveyor was unsuccessful and a message was left. Record review of the facility policy titled Documentation of Medication Administration revised 04/2007 revealed, 1- a nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2- Administration of medication must be documented immediately after (never before) it is given. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, 4medications are administered in accordance with prescriber orders, including any required time frame. 7medications are administered within 1 hour of their prescribed time, unless otherwise specified. Record review of the facility policy titled Medication Orders and Receipt Record revised 04/2007 revealed, 4- medications should be ordered in advance, based on the dispensing pharmacy's required lead time. 676252 Page 3 of 3