Health inspection·September 8, 2022

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 of 5 residents reviewed for medication administration. (Residents #1, #2, #3, #4 and #5). The facility failed to: -administer medications within the specified timeframes for Residents #1, #2, #3, and #4, and -accurately account for Resident #5's prescribed, controlled drug of Clonazepam. These failures placed residents at risk of not receiving the therapeutic benefits of prescribed medications and misappropriation or drug diversion. Findings included: Resident #1: Review of Resident #1's Face Sheet indicated the resident was admitted to the facility on [DATE] with the diagnoses including COVID-19, pain, high blood pressure, high cholesterol, inflammation of the stomach and intestines, insomnia, major depressive disorder, and anxiety disorder. In an interview on 09/06/22 at 04:04 PM with Resident #1, the resident said, I get my nighttime medication anytime between 10:30 PM and 1:30 in the morning. That's too late at night for me. Review of Resident #1's Physician Orders found no order for Melatonin. Review of Resident #1's MAR, dated 8/26/22 to 9/02/22, indicated Resident #1's Melatonin 3 mg was to be administered each night at 8:00 PM. Further review of the MAR reflected the following administration information: -On 8/30/22, LVN D administered Melatonin 3mg at 10:00 PM (2 hours late), and -On 9/03/22, LVN C administered Melatonin 3mg at 10:39 PM (2.75 hours late). In an interview on 09/08/22 at 01:54 PM with LVN D, LVN D said of the late medication Page 1 of 4 676256 676256 09/08/2022 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administration time on 08/30/22, I don't remember. I've worked a lot since then. LVN D also said, The melatonin is to help her sleep, so if she got it late, it would delay her sleep and not give her adequate rest. In an interview on 09/08/22 at 02:31 PM with LVN C, LVN C said of the late administration time on 09/03/22, She wasn't ready when I came in, she was watching a movie, so she asked me to come back later. Resident #2: Review of Resident #2's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including prostate enlargement with recurrent urinary tract infections, pneumonia, high blood pressure, low oxygen in the blood, low thyroid hormone, insomnia, and gastric reflux. Review of Resident #2's Physician Orders, dated 8/17/22, revealed an order for Trazodone 50 mg once a day. Review of Resident #2's MAR and TAR records from August 2022 and September 2022 reflected Resident #2 was to receive Trazodone 50 mg at 8:00 PM every night. Further review of the MAR and TAR records reflected the following information: -On 8/24/22, LVN G administered Trazodone at 11:23 PM (3.25 hours late), -On 8/25/22, LVN G administered Trazodone at 10:42 PM (2.75 hours late), -On 8/28/22, LVN C administered Trazodone at 10:46 PM (2.75 hours late), and -On 9/02/22, LVN C administered Trazodone at 10:02 PM (2 hours late). In an interview on 09/08/22 at 02:31 PM with LVN C, LVN C said of the late administration times on 08/28/22 and 09/02/22, I can't remember. LVN C said when a resident received medication intended to aid in sleep later than the scheduled administration time, They will be awake longer at night and sleep late in the morning. Resident #3: Review of Resident #3's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including joint problems following stroke, generalized anxiety disorder, high cholesterol, osteoporosis, osteoarthritis, atrial fibrillation, pain, vascular dementia, bipolar disorder, Parkinson's disease, and difficulty speaking and swallowing after stroke. Review of Resident #3's Physician Orders, dated 3/27/21, revealed an order for Pravastatin 20mg at hour of sleep. Review of Resident #3's MAR and TAR records from August 2022 and September 2022 reflected Resident #3 was to receive Pravastatin 20 mg at 8:00 PM nightly. Further review of the MAR and TAR records reflected the following information: -On 8/29/22, LVN J administered Pravastatin at 9:59 PM (2 hours late), and 676256 Page 2 of 4 676256 09/08/2022 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0755 -On 9/03/22, LVN I administered Pravastatin at 10:11 PM (2.25 hours late). Level of Harm - Minimal harm or potential for actual harm In an interview on 9/09/22 at 1:37 PM with LVN I, LVN I said of the late medication administration time on 09/03/22, I don't recall giving her medicine. I don't work full time at [name of facility]. I am PRN. LVN I said, The medication is supposed to be given at the time the doctor orders it. Residents Affected - Some Resident #4: Review of Resident #4's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, type 2 diabetes, high blood pressure, obesity, chronic obstructive pulmonary disease (disease affecting the lungs, making it difficult to breathe), peripheral neuropathy (disease of the nerves in hands and feet), generalized muscle weakness, swelling, major depressive disorder, and insomnia. Review of Resident #4's MAR records from August 2022 and September 2022 indicated Resident #4 was to receive Buspirone 5 mg twice daily at 8:00 AM and 7:00 PM. Further review of the MAR records reflected the following information: -On 8/29/22, LVN J administered Buspirone at 10:02 PM (3 hours late), -On 8/27/22, CMA H administered Buspirone at 9:14 PM (2.25 hours late), and -On 9/04/22, CMA H administered Buspirone at 9:07 PM (2 hours late). Attempts were made to contact CMA H via telephone on three separate occasions without success. In an interview on 09/08/22 at 02:22 PM with LVN J, LVN J said of medication administration times, The doctor who prescribed the medication may have a reason why it is due at a certain time. If you try 2-3 attempts, and a resident does not want to take the medication, you document and let the supervisor know. LVN J said of a medication being administered two hours late, It may have a side effect on the patient, the doctor has a reason why it is due at a certain time. In an interview on 09/08/22 at 02:58 PM with the Acting DON, he said, When I spoke to the nurses, they say that sometimes when they go into the room the patient is not ready and says come back later. Sometimes an emergency happens, like a code or a fall, and that puts them behind. The Acting DON said of medications being administered late, It depends on the medications . some medications, there could be harm if the timeframe is not what it's supposed to be . There could be drug interactions. Resident #5: Review of Resident #5's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, difficulty swallowing, cerebrovascular disease (disease of the blood vessels of the brain), deep vein thrombosis (a blood clot in the leg), type 2 diabetes mellitus, high blood pressure, insomnia, psychosis, metabolic encephalopathy (brain disease caused by chemical imbalance in the blood), Parkinson's Disease, and anxiety disorder. Review of Resident #5's MAR records from September 2022, dated 9/09/22, indicated the resident was to receive Clonazepam 0.5 mg two times daily, at 8 AM and at 8 PM. 676256 Page 3 of 4 676256 09/08/2022 San Remo 3550 N Shiloh Rd Richardson, TX 75082

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of the medication cart on 9/07/22 at 7:35 AM revealed LVN E counted 2 tablets of Clonazepam 0.5mg remaining for Resident #5. Review of the narcotic binder indicated that Resident #5 was documented to have 3 tablets of Clonazepam 0.5mg remaining, resulting in a discrepancy. In an interview on 9/07/22 at 7:40 AM with LVN E, LVN E said of the medication discrepancy, I think they forgot to record when they gave it last time. In an interview on 09/07/22 at 11:13 AM with the Acting DON, he explained that when the nurses on Resident #5's hall counted narcotics during the evening shift on 9/06/22 and during the morning shift on 9/07/22, they did not notice the Clonazepam 0.5 mg discrepancy for Resident #5. According to the Acting DON, the error occurred on the 2:00 PM, to 10:00 PM shift, when LVN F took the Clonazepam 0.5mg out of the blister pack to administer to Resident #5 at 8:00 PM. LVN F recorded the medication administration in the MAR but forgot to record the administration in the narcotic binder. LVN F had since corrected the error and all nurses involved had been in-serviced on medication reconciliation. In an interview on 09/08/22 at 02:39 PM with LVN F, she said on 9/06/22, she gave Clonazepam 0.5mg to Resident #5 at 8:00 PM and then recorded the medication administration in the MAR. LVN F stated, I did the narcotic count but didn't notice the discrepancy. They called me later to come sign the book. I just started working here on Monday, 9/04/22, so I didn't know the process really well. Review of the facility's Documentation of Medication Administration on eMAR/eTAR policy, dated February 2010, reflected, .Medications must be administered within the required time (60 minutes before or after) the time in the eMAR/eTAR . Review of facility's Management of Controlled Medications policy, undated, reflected, .Controlled medications will be counted every shift change (scheduled or incidental by an authorized staff member (RN/LVN/CMA) reporting on duty with an authorized staff member reporting off duty . 676256 Page 4 of 4