Health inspection·September 1, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1of 6 residents (Resident #1) reviewed for significant medication errors. Residents Affected - Some The facility did not provide Resident #1's physician ordered Potassium Chloride ER Tablet for four days. The noncompliance was identified as PNC. The IJ began on 8/12/2023 and ended on 8/17/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet, dated 8/25/23, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Stage 3 kidney disease (means your kidneys have moderate damage that impairs their ability to filter waste and toxins from your blood), hyperlipidemia (means your blood has too many lipids (or fats), hypertension (means that your blood is pumping with more force than normal through your arteries), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), lung cancer, heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), and iron deficiency anemia (type of anemia that develops if you do not have enough iron in your body). Record review of Resident #1's lab results, dated 8/11/23, revealed her potassium level was 2.5, reference range 3.5 - 5.1. Record review of Resident #1's nurse note, dated 8/11/23, revealed the facility received critical labs from the laboratory, that residents K+ was 2.5. Notified doctor of results. Received orders to start Potassium Chloride 20 MEQ BID. Record review of Resident #1's physician order, dated 8/11/23, revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ, give 1 tablet by mouth two times a day for Hypokalemia (a metabolic imbalance characterized by extremely low potassium levels in the blood). Order date Page 1 of 11 676262 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0760 8/11/23, Start date 8/12/23, End date 8/18/23. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident' #1's MAR from 8/1/23 to 8/31/23 revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ, give 1 tablet by mouth two times a day for Hypokalemia. Start date 8/12/23 at 6:00 AM, Discontinued date 8/18/23 at 12:56 PM. The MAR indicated Resident #1 received the medication as prescribed from 8/12/23 to 8/15/23. Residents Affected - Some Record review of Resident #1's lab results, dated 8/15/23, revealed her potassium level was 2.1, reference range 3.5 - 5.1. Record review of Resident #1's nurse note, dated 8/15/23, revealed the facility received critical low Potassium lab of 2.1. Also, received order to administer Potassium Chloride ER Tablet Extended Release 20 MEQ (2 tablets) now and 2 tablets after an hour. Record review of Resident #1's nurse note, dated 8/15/23, revealed the ADON wrote she spoke with the doctor regarding new orders for potassium and discussed sending Resident #1 to emergency room for critical lab level of potassium 2.1. Received new order per doctor to send Resident #1 to emergency room for evaluation. Charge nurse notified and instructed to call emergency room to give report and family to notify. Record review of Resident #1's incident report, dated 8/15/23, revealed the DON wrote the following: Nursing Description: Staff notified DON that [Resident #1] Potassium level was still low and now critically low K+ level, The PCP was notified and new orders were placed to give 40 meqs now and 40 meqs in 1 hour. Resident Description: [Resident #1] was alert and oriented with no N/V or chest pain she was unable to remember if she had received the K+ as scheduled. Description: Investigation began, called PCP due to [Resident #1] needing to be closely monitored, out of caution. Called all med aids and asked about administering the potassium they had all documented that it had been given. checked med cart K+ was not on cart. Checked med room, medication was available in medroom; no medications had been punched out of the card. Record review of Resident #1's hospital note, dated 8/15/23, revealed abnormal labs as chief complaint. Also, during emergency room evaluation, Resident #1 was alert and oriented, denied chest pains, palpitations, or shortness of breath. Hypokalemia, potassium was 2.1 on arrival. Potassium lab retaken in emergency room and was 2.1. During an interview with Resident #1's family member on 8/25/23 at 5:03 p.m., she said Resident #1's potassium was seriously low, and she missed at least 3 days of getting potassium medications because it was not given and as a result Resident #1 was admitted into the hospital on 8/15/23. She said Resident #1 told her at the hospital her heart felt like it was beating faster. During an interview on 8/25/23 at 2:30 p.m., the DON said Resident #1 currently had lung cancer and declined all treatments for cancer. She said Resident #1's health declined within the last couple of months and was on Hospice services. The DON stated the complaint visit was regarding Resident #1 due to medication error with potassium, four days was missed, and Resident #1 was sent to the 676262 Page 2 of 11 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some hospital due to critical low potassium level. The DON said CMA B, CMA C, LVN D and CMA E were terminated due to documenting on the MAR they administered Resident #1's Potassium medication when they did not give Resident #1 her potassium medication. She said Resident #1's, 8/11/23, potassium labs came back low 2.5, the doctor ordered potassium and labs were done again on 8/15/23 but potassium results were more critically low, 2.1, which was lower than on 8/11/23. The DON said she was alerted and concerned by the 8/15/23 lab levels because Resident #1 was taking Potassium twice a day from 8/12/23 to 8/15/23 and potassium level should have improved. The DON said she personally went to the med cart and looked for Resident #1's potassium medication and did not find it, she said she found Resident #1's potassium in the medication room unopened and said, it was no way CMAs was giving Resident #1 her potassium medicine. The DON said Resident #1 never received Potassium after receiving the initial dose on 8/11/23. During an interview on 8/25/23 at 7:15 p.m., the DON said Resident #1 missed potassium medication on the following dates: 8/12/23, 8/13/23, 8/14/23 and 8/15/23 and was sent to the hospital on the 15th. During a telephone interview on 8/27/23 at 3:57 p.m., CMA B said she was terminated due to a medication error. She said on 8/14/23 she was rushing and did not see Resident 1's new potassium order and did not realize she marked the MAR which indicated it was given. CMA B said the DON asked for her to get Resident #1's potassium medication off the medication cart and she did not see it. During a telephone interview on 8/27/23 at 4:22 p.m., CMA C said on 8/15/23 she received a call from the DON regarding Resident #1's potassium medication. She said the DON explained Resident #1's potassium was extremely low and the new order for potassium was not given. CMA C said Resident #1's MAR was marked that potassium was given, but it was not. She said she was not aware she marked the medication was given and said she made a mistake because it was not intentional. CMA C said Resident #1's potassium medication was found in the medication room, and she had access to the medication room. She said the steps to administer medications were to first, read the MAR second, look at medication, check the dosage, check the resident name and third, administer the medication. CMA C said on 8/22/23 she received a call from the DON explaining she was terminated due to falsification of documentation on Resident #1's MAR. During a telephone interview on 8/27/23 at 5:21 p.m., LVN D said on 8/15/23 she received a call from the DON and the ADON asking if she gave Resident #1 her potassium medication. LVN D said she did not falsify documentation, because she gave Resident #1 another resident's potassium medication from the med cart. LVN D said she knew what she did was wrong, but she was busy giving meds and did not have time to go track down Resident #1's potassium medication so she borrowed another resident's med. LVN D said she could not recall what resident she borrowed the potassium pill from and did not document she gave another residents medication and did not notify the DON or the ADON on what she did. LVN D said the steps for administering medications were first, look at the MAR second, check dosage, check patient name, make sure order match MAR, check time and route, third, administer medication. She said she was suspended effective 8/15/23 and received another call on 8/22/23 that she was terminated for falsifying documentation. LVN D said the facility would not allow her to return to facility and felt the facility was throwing her and the other three staff under the bus because they were possibly trying to cover up something. During a telephone interview on 8/27/23 at 5:32 p.m., CMA E said on 8/12/23 Resident #1's Potassium order had changed, and she was not aware. She said on 8/19/23 she received a call to return to the facility regarding Resident #1 critical low potassium. CMA E said she never saw Resident #1's 676262 Page 3 of 11 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some potassium on the med cart or listed on the MARs. The DON showed her Resident #1's MAR in question; CMA E said she was busy with 60 residents and tried to give them all their medications, so it was possible that she was rushing and accidently clicked she gave Resident #1 her potassium medication when she did not administer the medicine. CMA E said it was not intentional to falsify Resident #1's MAR. CMA E said when administering medications she first, compared the medication card to MAR; second she looked at the resident name, dosage and medicine to make sure everything was correct and third, she administered the medication. Record review of immediate response plan due to potential medication administration error, dated 8/15/23, indicated Resident #1 was noted with and abnormal K+ level. On 8/15/23 it was noted Resident #1 had an order for Potassium 20 meq by mouth twice a day to start the morning of 8/12/23. Medication was not administered per doctors' orders. Resident was assessed and stable. Immediate Response: As soon as potential medication error was identified nursing immediately assessed the resident. Outcome Resident #1 presented stable, MD notified of abnormal lab results and potential medication error notification. Out of an abundance of caution MD ordered that resident be sent to the ER for evaluation and treatment as indicated. Risk Response: All residents prescribed a potassium supplement medication were assessed. Outcome No negative outcomes or changes in condition were identified. Date Completed: 8/15/2023 *DON/ADON interviewed licensed nurse and medication aides responsible for the medication error. *DON/ADON re-educated: Proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. The Medication Administration policy was established 3/2019. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. -What to do if the medication was not on the cart and not available for administration example: check the medication room, check the carts thoroughly and if not located for medication aids, the med aid must notify the nurse, so that the nurse can ensure the needed medication was retrieved from the stat safe (emergency medication cart) so that the medication may be administered as ordered. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication and the nurse are to contact the MD to report status of the medication not being available for administration and following any additional orders provided. Date commenced: 8/15/23; Date completed: 8/15/23. *DON/ADON conducted an audit to validate all other residents who had an active potassium order had the correct medication available on the carts for administration and to ensure the medication was being administered as ordered. Audit was completed on 8/15/23. Outcome - Results of the potassium order audit revealed no medication administration discrepancies, and all potassium medications were available, on the carts and administered as per physician's orders. Date Completed: 8/15/23. 676262 Page 4 of 11 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some *DON/ADON/Designee conducted interviews and an audit on MARS and medication carts were in order to validate those medications was available and being administered ordered. Outcome - No negative outcomes or changes in condition were identified. Date completed: 8/17/23. Systemic Response: DON/ADON will ensure all licensed nurses and medication aids (full -time, part - time, newly hired nurses and med aids and any agency staff) will receive the in-service prior to working their next shift. In-service training and re-education will be provided to all licensed nurses and medication aides regarding topics by the DON/ADON: *Re-education consisted of the following topics: Proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. The Medication Administration policy was established 3/2019. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. What to do if the medication was not on the cart and not available for administration example: check the medication room, check the carts thoroughly and if not located for medication aids, the med aid must notify the nurse, so that the nurse can ensure the needed medication was retrieved from the stat safe (emergency medication cart) so that the medication may be administered as ordered. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication and the nurse are to contact the MD to report status of the medication not being available for administration and following any additional orders provided. Date commenced: 8/15/23; Date completed: 8/15/23. *DON/ADON will ensure all licensed nurses and medication aids (full -time, part - time, newly hired nurses and med aids and any agency staff) will receive the in-service prior to working their next shift. * DON/ADON/Designee conducted interviews and an audit on MARS and medication carts were in order to validate those medications was available and being administered ordered. Outcome - No negative outcomes or changes in condition were identified. Date completed: 8/17/23. *IDT (to include but not limited to: Administrator/DON/ADON) and Medical Director conducted an QAPI to review issue and community's response plan in place. Date of completion: 8/18/23 Monitoring Response: The DON/ADON will conduct random at least weekly (1-7 days per week) audit of physician orders to validate availability of medications on the carts and observations of medication administration to validate medication administration competency. DON/ADON will conduct daily reviews during clinical start - up meeting (1-7days per week) review of new medication orders, pertinent lab results (K+ levels), progress notes, and nursing 24-hour report to ensure that appropriate interventions are in place as well as any additional follow up has been assigned. 676262 Page 5 of 11 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some This plan will remain in place for the next two months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next two months. Interviews and record reviews were conducted on 8/28/23 from 6:00 p.m. through 8:00 p.m. and on 8/29/23 from 1:35 p.m. through 4:00 p.m., and included 3 RNs, 3 LVNs, 3 CMAs, and DON. Staff said they were trained on medication administration, documentation, medication refill process, and what to do if medications were not available. Staff were able to explain the proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. The Medication Administration policy was established 3/2019. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. Staff had knowledge on what to do if the medication was not on the cart and not available for administration example: check the medication room, check the carts thoroughly and if not located for medication aids, the med aid must notify the nurse, so that the nurse can ensure the needed medication was retrieved from the stat safe (emergency medication cart) so that the medication may be administered as ordered. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication and the nurse are to contact the MD to report status of the medication not being available for administration and following any additional orders provided. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: CMA B; Date of Policy violation: 8/14/23; Summary of violation: Medication administration error documented meds were given when they were not. Falsified MAR document; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: CMA C; Dates of policy violation: 8/12/23 and 8/13/23; Summary of violation: Administered medication incorrectly - falsified MAR document stating med was given when it was not; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice dated 8/15/23 revealed the following: Staff: LVN D; Dates of policy violation: 8/12/23; Summary of violation: Administered medication incorrectly - falsified MAR document and charted med was given when it was not; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice dated 8/15/23 revealed the following: Staff: CMA E; Dates of policy violation: 8/14/23 and 8/15/23; Summary of violation: Did not administer med as directed - falsified MAR document; Suspended effective 8/15/23 pending investigation results. Record review of Medication administration Policy dated 3/15/19 revealed Resident medications are administered in an accurate, safe, timely, and sanitary manner .Documentation: Initial the electronic administration record after the medication is administered to the resident. The noncompliance was identified as PNC. The IJ began on 8/12/2023 and ended on 8/17/2023. The facility had corrected the noncompliance before the survey began. 676262 Page 6 of 11 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 on observation, interview and record review, the facility failed to ensure, in accordance with State and Federal laws, medications were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 3 of 5 medication carts (100 Hall and 200 Hall Medication Carts) reviewed for pharmacy services. 1. RN G failed to ensure the Nurse Medication cart for 100 Hall was not left unlocked, unsecured, and unattended. 2. The facility failed to ensure the Nurse Medication Cart for 100 Hall and 200 Hall were not left unlocked, unsecured, and unattended near the nurse station. 3. The facility failed to ensure two medications (Fluticasone Propionate Nasal Spray 50 mcg and Ultra Lubricant Eye Drops) were left at Resident #2's bedside. 4. The facility failed to ensure CMA F did not leave a bottle of medication Phenytoin Extended Caps 100 mg (used to prevent and control seizures) on top of the 100 Hall medication cart unsecured, and unattended. These failures could place residents, of drug diversions or misuse of medications. Findings included: During an observation on 8/28/23 at 6:47 p.m., revealed the Medication cart for 100 hall had a bottle of Phenytoin Extended Caps 100 mg (used to prevent and control seizures) with three capsules unsecured and unattended on top of the cart. The cart was locked, and unattended for a few minutes. Residents and staff were observed passing by the medication cart. During an observation and interview on 8/29/23 at 1:51 p.m., Resident #2 had a box of Fluticasone Propionate Nasal Spray 50 mcg (used to relieve seasonal and year-round allergic and non-allergic nasal symptoms, such as stuffy/runny nose, itching, and sneezing); opened 7/23/23 and a box of Ultra Lubricant Eye Drops - Polyethylene glycol 400 0.4% & Propylene glycol 0.3% (medication is used to relieve dry, irritated eyes ); opened 7/9/23. She was walking out of her room and looked for a nurse to return the medications too. Resident #2 said a nurse gave her the medications earlier that morning for her to self-administer whenever she returned from therapy and now, she was ready to give them back. She said it was not her normal nurse, and she said she hoped she did not get anyone in trouble, but she just wanted to return the medications so she would not lose them. The State Surveyor gave both medications to the Administrator who was walking past Resident #2 room. During an observation on 8/29/23 at 2:37 p.m., revealed on 100 Hall a Nurse Medication Cart was unlocked and unattended on the hall by room [ROOM NUMBER]. All the drawers of the medication cart could be opened, and the medication were easily accessible. The cart was unattended. Residents were observed passing by the medication cart. During an observation on 9/1/23 at 10:50 a.m., 200 Hall Nurse Medication Cart was unlocked and 676262 Page 7 of 11 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unattended near the nurses station. All the drawers of the medication cart could be opened, and the medications was easily accessible. The cart was unattended for an unknown amount of time. Residents were observed passing by the medication cart. The State Surveyor informed the DON regarding the unlocked cart and the DON locked the cart. During an observation on 9/1/23 at 10:52 a.m., revealed the 100 Hall Nurse Medication Cart was unlocked and unattended near the nurses station. All the drawers of the medication cart could be opened, and the medications were easily accessible. The cart was unattended for an unknown amount of time. Residents were observed passing by the medication cart. The State Surveyor informed DON regarding the unlocked cart and DON locked the cart. During an interview on 8/28/23 at 6:50 p.m., CMA F said she left the medication on top of the cart because the resident was no longer on 100 Hall and had moved to 200 Hall, so she left the medication on top of the cart to put in the correct cart whenever she finished passing meds on the 100 hall. CMA F said she made a mistake because all meds should be locked away and the medication cart should be locked every time she walked away from the cart. During an interview on 8/29/23 at 2:39 p.m., RN G returned to the medication cart. The State Surveyor pointed out the nurse cart was left unlocked and unattended, and RN G said the medication carts were never supposed to be left unlocked and she didn't know why she did it, it was a mistake. During an interview on 9/1/23 at 11:15 a.m., the DON said medication carts should remain locked and secured anytime they were not attended. She said no medications should be left at the residents bedside unless the resident was assessed to self-administer; she said the facility did not have any residents who self-administered therefore, no medications should be at the bedside to self-administer. Record review of the medication cart use and storage policy, dated 3/15/19, revealed .1)Security: * The medication cart and its storage bins are kept locked until the specified time of medication administration. * If an emergency occurs during the medication pass, the nurse/medication aide securely locks the medication cart before attending to the emergency situation. * During routine administration of medications, the cart may be kept in the doorway of the resident's room with: - drawers unlocked and facing inward, and within sight of the nurse -no medications are kept on top of the cart. 676262 Page 8 of 11 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented, for 1 of 6 residents (Resident # 1) reviewed for resident records. The facility failed to accurately record Resident #1's Potassium Chloride ER on the MAR from 8/12/23 to 8/15/23. This failure could place residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication, a delay in services or a potential decline in resident 's health. Findings include: Record review of Resident #1's face sheet, dated 8/25/23, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Stage 3 kidney disease (means your kidneys have moderate damage that impairs their ability to filter waste and toxins from your blood), hyperlipidemia (means your blood has too many lipids (or fats), hypertension (means that your blood is pumping with more force than normal through your arteries), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), lung cancer, heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), and iron deficiency anemia (type of anemia that develops if you do not have enough iron in your body). Record review of Resident #1's lab results, dated 8/11/23, revealed her potassium level was 2.5, reference range 3.5 - 5.1. Record review of Resident #1's physician order, dated 8/11/23, revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ, give 1 tablet by mouth two times a day for Hypokalemia (a metabolic imbalance characterized by extremely low potassium levels in the blood). Order date 8/11/23, Start date 8/12/23, End date 8/18/23. Record review of Resident' #1's MAR from 8/1/23 to 8/31/23 revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ, give 1 tablet by mouth two times a day for Hypokalemia. Start date 8/12/23 at 6:00 AM, Discontinued date 8/18/23 at 12:56 PM. The MAR indicated Resident #1 received the medication as prescribed from 8/12/23 to 8/15/23. Record review of Resident #1's nurse note, dated 8/15/23, revealed the ADON wrote she spoke with the doctor regarding new orders for potassium and discussed sending Resident #1 to emergency room for critical lab level of potassium 2.1. Received new order per doctor to send Resident #1 to emergency room for evaluation. Charge nurse notified and instructed to call emergency room to give report and family to notify. Record review of Resident #1's incident report, dated 8/15/23, revealed the DON wrote the 676262 Page 9 of 11 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0842 following: Level of Harm - Minimal harm or potential for actual harm Nursing Description: Staff notified DON that [Resident #1] Potassium level was still low and now critically low K+ level, The PCP was notified and new orders were placed to give 40 meqs now and 40 meqs in 1 hour. Residents Affected - Some Resident Description: [Resident #1] was alert and oriented with no N/V or chest pain she was unable to remember if she had received the K+ as scheduled. Description: Investigation began, called PCP due to [Resident #1] needing to be closely monitored, out of caution. Called all med aids and asked about administering the potassium they had all documented that it had been given. checked med cart K+ was not on cart. Checked med room, medication was available in medroom; no medications had been punched out of the card. Record review of immediate response plan due to potential medication administration error, dated 8/15/23, indicated Resident #1 was noted with and abnormal K+ level. On 8/15/23 it was noted Resident #1 had an order for Potassium 20 meq by mouth twice a day to start the morning of 8/12/23. Medication was not administered per doctors' orders. Resident was assessed and stable. During an interview with Resident #1's family member on 8/25/23 at 5:03 p.m., she said Resident #1's potassium was seriously low, and she missed at least 3 days of getting potassium medications because it was not given and as a result Resident #1 was admitted into the hospital on 8/15/23. She said Resident #1 told her at the hospital her heart felt like it was beating faster. During an interview on 8/25/23 at 2:30 p.m.,the DON stated the complaint visit was regarding Resident #1 due to medication error with potassium, four days was missed, and Resident #1 was sent to the hospital due to critical low potassium level. The DON said CMA B, CMA C, LVN D and CMA E were terminated due to documenting on the MAR they administered Resident #1's Potassium medication when they did not give Resident #1 her potassium medication. She said Resident #1's, 8/11/23, potassium labs came back low 2.5, the doctor ordered potassium and labs were done again on 8/15/23 but potassium results were more critically low, 2.1, which was lower than on 8/11/23. The DON said she was alerted and concerned by the 8/15/23 lab levels because Resident #1 was taking Potassium twice a day from 8/12/23 to 8/15/23 and potassium level should have improved. The DON said she personally went to the med cart and looked for Resident #1's potassium medication and did not find it, she said she found Resident #1's potassium in the medication room unopened and said, it was no way CMAs was giving Resident #1 her potassium medicine. The DON said Resident #1 never received Potassium after receiving the initial dose on 8/11/23. During an interview on 8/25/23 at 7:15 p.m., the DON said Resident #1 missed potassium medication on the following dates: 8/12/23, 8/13/23, 8/14/23 and 8/15/23 and was sent to the hospital on the 15th. During a telephone interview on 8/27/23 at 3:57 p.m., CMA B said on 8/14/23 she was rushing and did not see Resident 1's new potassium order and did not realize she marked the MAR which indicated it was given. CMA B said the DON asked for her to get Resident #1's potassium medication off the medication cart and she did not see it. During a telephone interview on 8/27/23 at 4:22 p.m., CMA C said on 8/15/23 she received a call from the DON regarding Resident #1's potassium medication. She said the DON explained Resident #1's 676262 Page 10 of 11 676262 09/01/2023 The Heights of Tyler 2650 Elkton Trail Tyler, TX 75703

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some potassium was extremely low and the new order for potassium was not given. CMA C said Resident #1's MAR was marked that potassium was given, but it was not. She said she was not aware she marked the medication was given and said she made a mistake because it was not intentional. CMA C said Resident #1's potassium medication was found in the medication room, and she had access to the medication room. CMA C said on 8/22/23 she received a call from the DON explaining she was terminated due to falsification of documentation on Resident #1's MAR. During a telephone interview on 8/27/23 at 5:21 p.m., LVN D said on 8/15/23 she received a call from the DON and the ADON asking if she gave Resident #1 her potassium medication. LVN D said she did not falsify documentation, because she gave Resident #1 another resident's potassium medication from the med cart. LVN D said she knew what she did was wrong, but she was busy giving meds and did not have time to go track down Resident #1's potassium medication so she borrowed another resident's med. LVN D said she could not recall what resident she borrowed the potassium pill from and did not document she gave another residents medication and did not notify the DON or the ADON on what she did. She said she was terminated for falsifying documentation. During a telephone interview on 8/27/23 at 5:32 p.m., CMA E said on 8/12/23 Resident #1's Potassium order had changed, and she was not aware. She said on 8/19/23 she received a call to return to the facility regarding Resident #1 critical low potassium. CMA E said she never saw Resident #1's potassium on the med cart or listed on the MARs. The DON showed her Resident #1's MAR in question; CMA E said she was busy with 60 residents and tried to give them all their medications, so it was possible that she was rushing and accidently clicked she gave Resident #1 her potassium medication when she did not administer the medicine. CMA E said it was not intentional to falsify Resident #1's MAR. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: CMA B; Date of Policy violation: 8/14/23; Summary of violation: Medication administration error documented meds were given when they were not. Falsified MAR document; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: CMA C; Dates of policy violation: 8/12/23 and 8/13/23; Summary of violation: Administered medication incorrectly - falsified MAR document which stated med was given when it was not; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: LVN D; Dates of policy violation: 8/12/23; Summary of violation: Administered medication incorrectly falsified MAR document and charted med was given when it was not; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: CMA E; Dates of policy violation: 8/14/23 and 8/15/23; Summary of violation: Did not administer med as directed - falsified MAR document; Suspended effective 8/15/23 pending investigation results. Record review of medical records policy, dated February 2017, revealed A medical record is maintained for every person admitted to a community in accordance with accepted professional standard and practices. The administrator has ultimate responsibility for the maintenance of medical records but may delegate this responsibility to another team member. 676262 Page 11 of 11