Health inspection·June 8, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 inform residents in advance of the risks and benefits of proposed care for 3 (Residents #16, #179, #12) out of 35 residents reviewed for antipsychotics in that: Residents Affected - Some 1. The facility failed to obtain a written consent for the administration of Seroquel (antipsychotic) 25mg 1 PO Q12hr from Resident #16 or his legal representative. 2. The facility failed to obtain a written consent for the administration of Risperidone (antipsychotic) 1mg PO BID and Seroquel (antipsychotic) 50mg PO QHS from Resident #179 or her legal representative. 3. The facility failed to obtain a written consent ftom Resident #12 or his legal representative, for the administration of Imipramine HCL (antidepressant) 10mg 1 PO QHS, until ten days after the resident had already been taking the medication. This failure could place residents at risk of unwanted adverse drug reactions, risks of treatment the residents did not consent to, and from seeking alternative treatment. Findings include: 1. Record review of Resident #16's face sheet printed 6/8/23, indicated he is a [AGE] year-old male, admitted on [DATE], with diagnoses of anxiety disorder (intense fear/terror), Parkinson's disease (uncontrollable movements of the body), unspecified dementia (loses ability to think, remember, learn, make decisions, and solve problems), and depression (intense sad, loneliness, loss of interest/pleasure in daily activities). Record review of Resident #16's MDS dated [DATE] revealed a BIMS score of 7 out of 15, indicating severely impaired cognition, the resident required extensive assistance in multiple ADLs, used a wheelchair, had no hallucinations or behavioral/delusional problems, and had not taken antipsychotics before, but had taken antidepressants. Record review of Resident #16's chart revealed a medication order for Seroquel Tablet 25mg 1 PO Q12hr for hallucinations, that was ordered on 10/5/22 at 6:25pm by APRN [NAME]. Record review of Resident #16's chart revealed there was no consent in the chart for Seroquel. On 6/8/23 at 3:10pm, the facility submitted a consent with the provider's signature on it, but not the LAR's, for Seroquel 25mg 1 PO Q12hr, that was signed and dated on 6/8/23. Page 1 of 18 676306 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #16's MAR on 6/8/23, revealed the resident had been taking Seroquel 25mg 1 PO Q12hr for hallucinations, since October 2022. Record review of Resident #16's care plan dated 5/12/23, revealed, Resident uses psychotropic medications (Antipsychotic) r/t Hallucinations. Goals: Resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Resident will reduce the use of psychoactive medication through review date. Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Monitor/record occurrence of/for target behavior symptoms, such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. and document per facility protocol. Monitor/record/report to MD PRN side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia (uncontrolled, sudden, irregular movements of the face and body), EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea/vomiting, behavior symptoms not usual to the person. 2. Record review of Resident #179's face sheet printed 6/8/23, indicated she was an [AGE] year-old female, admitted on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness on the right side after a stroke), unspecified, aphasia following cerebral infarction (trouble swallowing after stroke), and depression (sadness/crying/hopelessness that interferes with daily activities). Record review of Resident #179's MDS, dated [DATE], revealed she came from an acute hospital, had no serious mental illness and no ID/DD, had a BIMS score of 0 out of 15 indicating severely impaired cognition, had no problems with mood, hallucinations, or delirium, did not require much help with ADLs, used a walker, and had been on antipsychotics and antidepressants in the last 3 days. Record review of Resident #179's medical records revealed an order for Risperidone 1mg PO BID for antipsychotic/manic, and Quetiapine Fumarate (Seroquel) 50mg PO QHS for antipsychotic agent, ordered by MD KR on 5/27/23 at 11:39pm. Record review of Resident #179's medical records revealed no consents for Risperidone or Seroquel. On 6/8/23 at 3:10pm, the facility submitted a written consent with the provider's signature on it, but not the LAR's, for Risperidone 1mg BID and Seroquel 50mg QHS, that was signed and dated 6/8/23. Record review of Resident #179's MAR on 6/8/23, revealed the resident had been taking Risperidone 1mg BID and Seroquel 50mg QHS since admission on [DATE]. Record review of Resident #179's baseline care plan dated 6/1/23, did not address her psychotropic usage. 3. Record review of Resident #12's face sheet printed 6/8/23, indicated he is a [AGE] year-old male, admitted on [DATE], with diagnoses of adjustment disorder with mixed disturbance of emotions and conduct (short term condition in a person who experiences an exaggerated reaction to a stressful/traumatic event), malignant neoplasm of larynx (cancer of the voice box), and weakness. Record review of Resident #12's MDS dated [DATE] revealed no serious mental illness and no ID/DD, 676306 Page 2 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he came from an acute hospital, had a BIMS score of 13 out of 15 indicating normal cognition, had no problems with mood, hallucinations, or delusions, was in a wheelchair and functional with ADLs, had an indwelling catheter, and had not been on any anti-psychotics, but had been on antidepressants for the past 6 days. Record review of Resident #12's medical records revealed an order for Imipramine HCL 10mg PO QHS on 5/2/23 at 5:01pm by MD KR. Record review of Resident #12's medical records revealed a written consent for Imipramine HCL, signed and dated on 5/12/23 by the resident. Record review of Resident #12's MAR on 6/8/23, revealed the resident had been receiving Imipramine HCL 10mg PO QHS since 5/3/23. Record review of Resident #12's care plan dated 5/17/21 stated: I use antidepressant medication r/t depression. Goals: I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: Educate me/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of antidepressant drugs. Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Monitor/document/report to MD PRN ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, neg. mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Interview with MD KR on 6/8/23 at 12:00pm she stated it was her expectation staff would get written consent for antipsychotics prior to the start of administration of the medication. She stated she spoke to the family/resident about the medication and the risks/benefits of it, and usually documented the conversation and the outcome in her note. She said the staff would then fill out the written consent and would put it in her binder she kept at the nurse's station, to be signed by her. Per the MD, every day she looked through the binder and signed new orders or consents that were in it. She also said staff should look for a consent before they gave the medication for the first time, to ensure it had been done. Record review of the facility's Psychoactive Medication Administration Policy (1/10) read in part: It is the policy to ensure all psychoactive medications are .not given without appropriate consent. 1. All residents have the right to .refuse to consent to the prescribing of psychoactive medication . 4. Nursing facility personnel may not administer a psychoactive medication to a resident who does not consent, or whose legal representative does not consent, to the prescription. 5. Consent for the administration of psychoactive medication given by either the resident or the person authorized by law to consent on behalf of the resident, is valid only if: .b. the person who prescribes the medication .provides the resident .with the following information in a single document used for the purpose of consent for psychoactive medication: specific condition to be treated, beneficial effects on the condition expected from the use of the medication, the probable clinically significant side effects and risks associated with the medication, as reported in the drug monograph ., the proposed course of the medication . d. consent is evidenced in the resident's medical record by: a signed form prescribed by the facility, a written statement by the physician who prescribed the medication that documents consent was given by the appropriate person and the circumstances under which consent was 676306 Page 3 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0552 Level of Harm - Minimal harm or potential for actual harm obtained. Implementation: .2. The nurse transcribing the medication order will attempt to obtain consent from the resident or responsible party and will complete the consent form with all necessary information.4. The nurse giving the initial dose will be accountable for verifying that the consent form has been completed and consent is properly documented. If the consent form is not present in the clinical record, the nurse will hold the initial dose until consent has been obtained. Residents Affected - Some . 676306 Page 4 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 electronically transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after the facility completed the resident's assessment for 1 of 3 closed records reviewed for MDS assessments. (CR #6) Residents Affected - Few The facility failed to transmit to the CMS system CR #6's discharge MDS assessment dated [DATE]. This failure could place the residents at risk for not having the MDS assessment transmitted as required. Findings include: CR #6 Electronic Record review of CR #6 revealed she was a-[AGE] year-old female admitted to the facility on [DATE]. Her Diagnoses included Urinary tract infection, Diabetes Mellitus, muscle weakness, cerebral ischemia, and Gout disease. CR #6 was discharged from the facility on 01/02/2023. Record review of CR#6 discharge MDS revealed it was completed on 01/02/2023 but not transmitted. Interview with the DON on 06/08/2023 at 2:00PM, she said the MDS should have been transmitted. She said she would find out what happened because she was not at the facility on 01/02/23. The facility's policy was requested at this time. Facility's policy on MDS transmission was not provided prior to exit on 06/08/23 at 5:00PM. The facility's Administrator and DON said they will E-mail the policy but was not received. . 676306 Page 5 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement baseline care plan with the necessary information to provide care for each resident within 48 hours of admission for 3 residents reviewed for baseline care plans (Resident # 79, 179, 182). --The facility failed to include required components in the base-line care plans for Residents #79 admitted [DATE], #179 admitted [DATE], and #182 admitted [DATE]. This failure could affect newly admitted residents and place them at risk of not receiving proper care and services based on their current conditions for continuity of care. Findings include: Resident #79 Record review of Resident #79's face sheet revealed admission date of 6/1/23, with diagnoses including stress fracture, hip, subsequent encounter for fracture with routine healing, anemia (deficiency of red blood cells in blood), hypertension (high blood pressure), heart failure (severe failure of the heart to function properly), acute kidney failure (inability of kidneys to filter waste from the blood), chronic kidney disease (longstanding disease of kidneys leading to renal failure), weakness. Observation and interview with Resident # 79 on 6/6/23 at 10:10 am revealed she was sitting on the side of her bed, with her walker at bedside. In interview at that time, she said she needed help to get up and she was waiting for someone to help. She said she does have physical therapy and they are doing a good job. Record review of Resident # 79's skilled evaluation dated 6/7/23 revealed a narrative note which read, in part: .resident continues skilled services, alert and cooperative, ambulates with walker in room with limited assist, participates in therapy per doctors' orders, sits in chair for meals, no respiratory distress noted, no c/o pain this shift . Record review of Resident #79's baseline care plan, dated 6/1/23, revealed there were 2 focus areas listed: I am at high risk for falls, and I have one or more pressure ulcers or potential for pressure ulcer development. The baseline care plan did not include admitting diagnosis, code status, assistance needed to complete daily skills, therapy orders, or required after- care for hip fracture. Record review of resident # 79's MDS (undated) revealed in progress. Resident #179 Record review of Resident #179's face sheet indicated she was an [AGE] year-old female, admitted on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness on the right side after a stroke), acute necrotizing hemorrhagic encephalopathy (brain damage usually following an acute disease with fever), unspecified, aphasia following cerebral infarction (trouble swallowing after stroke), essential hypertension (high blood 676306 Page 6 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pressure not caused by a medical condition), depression (sadness/crying/hopelessness that interferes with daily activities), and primary osteoarthritis (break down of cartilage in the joints). Record review of Resident #179's baseline care plan dated 6/1/23, revealed the resident had one focus area listed: Resident have little or no activity involvement r/t focus on rehab and recovery. The care plan did not list the resident's code status, fall risk, admission diagnosis, or that the resident was receiving IV antibiotics. Record review of Resident #179's MDS, dated [DATE], indicated under section A1700 and A1800 that the resident was admitted from an acute hospital. Resident had a BIMS score of 0 out of 15, indicating her cognition was severely impaired. Section G0600 of the MDS revealed the resident used a walker. The MDS did not have a UTI documented under section I0020. According to the MDS the facility was unable to determine if the resident had any prior falls in the last 6 months. Resident #179's MDS stated under section

K0510 that she was on a therapeutic diet. Under section N0410 the MDS stated Resident #179 had been taking antipsychotics, antidepressants, and antibiotics. Under section O0100 it stated the resident was receiving IV medications. Also, under section O, the resident was receiving Occupational and Physical Therapy. Record review of Resident #179's new resident report sheet dated 5/27/23 revealed a diagnosis of AMS r/t UTI, had a LA 20G IV placed 5/22/23, used a walker, was on a heart healthy diet, was full code, required a 2 person assist with the walker when transferring, and was on Rocephin and Azithromycin for the infection. Record review of Resident #179's admission progress note, by RN FF on 5/26/23 at 12:28am, revealed the admission diagnoses were AMS r/t UTI, and lactic acidosis. According to the note, the resident required a walker, and was on a heart healthy diet with thin liquids. Record review of Resident #179's nurse's note, by RN FF on 5/28/23 at 4:47am, revealed A right hand single lumen midline inserted by Dynamic infusion tech/nurse, indicated for IV antibiotics. Record review of Resident #179's progress note, by RN FF on 5/29/23 at 1:24am, revealed Resident is given IV Azithromycin daily for AMS r/t UTI, well tolerated with no adverse effect noted . Record review of Resident #179's informed consent for a midline insertion, dated 5/31/23 at 11:30pm, revealed it was for IV therapy that would be for more than 14 days. Resident #182 Record review of Resident #182's face sheet indicated he's an [AGE] year-old male, admitted on [DATE], with diagnoses of Parkinson's disease (brain disorder that causes uncontrollable movements), repeated falls, and unspecified atrial fibrillation (arrhythmia of the heart where the beat is irregular). Record review of Resident #182's baseline care plan, printed 6/8/23, revealed the resident had one focus area listed: I am high risk for falls r/t trying to get out of bed, not asking for assistance and/or waiting for assistance. Care plan does not reference the resident's code status, admission diagnosis, the Dementia or Parkinson's, or any other areas the resident requires to meet their needs. Resident #182's MDS was not available when requested, due to the resident being a new admission on 676306 Page 7 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0655 [DATE]. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #182's history and physical performed by APRN [NAME] on 6/2/23, revealed the resident had Parkinson's and dementia, requires pain management with Tramadol, is bed confined/dependent for transfers and gait, is on Eliquis and will need to be monitored for bleeding, has depression and is on Wellbutrin and Trazodone, and needs max assist with ADLs and personal care. Residents Affected - Some Record review of Resident #182's hospital medical records from Texas NeuroRehab Center dated 5/23/23 at 10:45am, revealed a minced and moist with thin liquids diet, and 1:1 assistance with meals. Record review of Resident #182's new admission report sheet dated 6/2/23 revealed a diagnosis of Parkinson's, a diet of minced and moist, a full code status, he required a hoyer lift for transfer, and he required his meds to be taken in pudding. Interview with the DON, on 6/8/23 at 10:47am, she revealed baseline care plans were created by the nurse who admitted the resident. She stated the care plan should be created as soon as the resident was admitted , but if not by the current nurse, then definitely by the nurse in the next shift. According to the DON, the baseline care plan should include at a minimum, the admitting diagnosis, fall risk, code status, and basic things the resident required to meet their needs. She said it should also include interventions for resident's that had needs that were not being met. Per the DON, if the baseline care plan did not have the necessary information or was not updated, the facility would not have an adequate treatment plan for the resident, and they would not be meeting the needs of the resident. Interview with MDS coordinator on 6/8/23 at 12:15 pm revealed they are trying to clean up the care plans and MDS assessments from the previous MDS nurse. She said the baseline care plan needs to be done within 48 hours of admission and is done by the admitting nurse and should contain the resident needs for care. She said the MDS coordinator was responsible for enusuring the care plans were accurate with information from the IDT team. Record review of the facility policy on Preliminary care Plans, undated, revealed, in part: .preliminary care plan will be developed within 24 hours of the resident's admission .the preliminary care plan will be used until staff can conduct the comprehensive assessment. . 676306 Page 8 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #181) out of 1 resident sampled for respiratory care in that: Residents Affected - Few LPN TS failed to assess Resident #181, including his lungs, before providing respiratory treatment. This failure could place residents at risk for a change in condition. Findings include: Record review of Resident #181's face sheet printed 6/8/23, indicated he is a [AGE] year-old male, admitted on [DATE], with diagnoses of disorder of urea cycle metabolism (genetic condition that causes ammonia to build up in the blood), hypo-osmolality and hyponatremia (low sodium levels in the blood), hypokalemia (low potassium levels in the blood), rhabdomyolysis (damaged muscle tissue that release proteins and electrolytes into the blood), other acute kidney failure (sudden failure of the kidneys), and hypothermia (low body temperature). Record review revealed no MDS data for Resident #181. Record review of Resident #181's medical record revealed an order for Budesonide Inhalation Suspension .25mg/2ml, 4ml via nebulizer BID for bronchodilation (widening of the airways), ordered by APRN [NAME] on 6/6/23 at 10:57pm. Observation of LPN TS on 6/7/23 at 9:50am, revealed she instilled the Budesonide Inhalation Suspension .25mg/2ml, 4ml into the nebulizer cup and attached it to the mask. LPN then went into the room of Resident #181 and attached the mask to the nebulizer machine at the bedside and turned it on. The machine was not working, and medication was not coming out of the nebulizer. LPN TS went and retrieved a new machine and attached the mask with the medication to it. She placed the mask on Resident #181 and turned the nebulizer on. Medication was coming out of the nebulizer on the resident's face. She checked the resident's oxygen saturation on his finger after the machine was on, and it was 93%. LPN TS did not assess Resident #181's lungs, heart, or respirations at any point before administering the treatment. Interview with LPN TS on 6/7/23 at 10:15am, she stated the last time she assessed Resident #181's lungs were at the start of her shift at 7am. She said it was policy to assess the resident's lungs before and after treatment. She also said that Resident #181's lung sounds could have changed between 7am and 10am, and she would have missed the change in condition without assessing the resident. Record review revealed no care plan for Resident #181. Record review of the facility's policy and procedures for Administering Medications Through a Small Volume (Handheld) Nebulizer (Revised October 20110) read in part: Steps in the Process: 6. Obtain baseline pulse, respiratory rate and lung sounds. Reporting: 4. Notify the Physician if the pulse rate during treatment increases 20 percent above baseline. . 676306 Page 9 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

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 ensure that drug records were in order and that an account of all controlled drugs was maintained for 1 (Hall 200 Nurse Cart) out of 3 medication carts sampled for medication storage in that: -Hall 200 Nurse's Cart (Labeled HC South) had an actual count of 8 Tramadol 50mg tablets for Resident #182, when the resident's-controlled drug receipt/record/disposition form documented 11. This failure could place residents at risk of running out of their medications by the facility not ordering the medication timely, and risk of maintaining their highest practicable mental, physical, and psychosocial well-being. Findings Include: Record review of Resident #182's face sheet printed 6/8/23, indicated he is an [AGE] year-old male, admitted on [DATE], with diagnoses of Parkinson's disease (uncontrollable movements of the body), repeated falls, and atrial fibrillation (irregular heart rhythm). Record review of the facility's Controlled Drugs-Count Record for the Hall 200 (HC South) Nurse's cart for June 2023, reviewed on 6/8/23 at 10:37am, revealed missing signatures for the date of 6/7/23. The 7am to 3pm off going nurse and 3pm to 11pm on coming nurse for 6/7/23 did not sign the sheet, acknowledging they counted the controlled drugs on hand and agreed with the quantity of each medication, matched the number on the Controlled Drug Administration Record. Record review of Resident #182's Controlled Drug Receipt/Record/Disposition Form reviewed on 6/8/23 at 10:37am, revealed on 6/6/23 there were 11 Tramadol 50mg tabs, and the resident was ordered to have the medication 1 tablet TID. The date of 6/7/23 was not entered on the log. Observation of the nurse's medication cart for Hall 200 (HC South) on 6/8/23 at 10:37am, revealed a count of 8 tabs of Tramadol 50mg for Resident #182. The ADON and RN VK confirmed a count of 8 tabs of Tramadol 50mg for Resident #182. Interview with the ADON on 6/8/23 at 10:40am, she stated it was policy for the nurses to count the controlled medications at shift change. Interview with RN VK on 6/8/23 at 10:40am, she stated staff were expected to count the medication cart at the start and end of every shift. She said she did not count prior to her shift today because the off going nurse was in a rush and was not able to stay for the medication count. Per RN VK, she should have notified the DON if the previous shift was unable to stay for the medication count and will do so going forward. Also, RN VK said if she did not count the medication cart and the count was off, drug diversion could be suspected, and she could be in trouble. Record review of the facility's policy and procedures for Controlled Substances (revised December 2012) read in part: Policy Interpretation and Implementation: 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing 676306 Page 10 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0755 Level of Harm - Minimal harm or potential for actual harm Services. 10. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify responsible parties and shall give the Administrator a written report of such findings. 11. The Director of Nursing Services shall consult with the provider pharmacy and the Administrator to determine whether any further legal action is indicated. Residents Affected - Few . 676306 Page 11 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from unnecessary anti-psychotropic drugs, and residents who use anti-psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, for 3 (Resident #16, Resident #179, Resident #12) of 35 residents reviewed for Psychotropic Medication use in that: 1. Resident #16 did not have an adequate indication for usage of Seroquel (antipsychotic) 25mg BID. Resident #16 did not have an adequate reason documented as to why a gradual dose reduction of the Seroquel 25mg BID was not done, and the resident had been on it since 10/5/22. 2. Resident #179 did not have an adequate indication for usage of Risperidone (antipsychotic) 1mg PO BID and Seroquel 50mg QHS. 3. Resident #12 did not have an adequate indication for usage of Imipramine (antidepressant) 10mg QD. These failures could place residents at risk of maintaining their highest practicable mental, physical, and psychosocial well-being, as well as risk for potential adverse drug reactions. Findings include: 1. Record review of Resident #16's face sheet printed 6/8/23, indicated he is a [AGE] year-old male, admitted on [DATE], with diagnoses of anxiety disorder (intense fear/terror), Parkinson's disease (uncontrollable movements of the body), unspecified dementia (loses ability to think, remember, learn, make decisions, and solve problems), and depression (intense sad, loneliness, loss of interest/pleasure in daily activities). Record review of Resident #16's MDS dated [DATE] revealed a BIMS score of 9 out of 15, indicating moderately impaired cognition. Section C1310 asked about signs and symptoms of delirium, and No was selected for any evidence of an acute change in mental status from baseline. Under section D for mood, Resident #16 had no reported symptoms. E0100, Potential Indicators of Psychosis, none of the above was selected related to hallucinations and delusions. Section I, Active Diagnoses, had non-Alzheimer's Dementia marked as well as Parkinson's, and anxiety. N0410 had 7 days marked for antipsychotics, 0 days marked for anti-anxiety, 7 days marked for antidepressants, and 0 for hypnotics, for the number of days taken. For N0450, Antipsychotic Medication Review, yes was selected indicating the resident had been taking antipsychotics on a routine basis. On the next question, no was selected indicating a gradual dose reduction had not been attempted, and a GDR had not been documented by a physician as clinically contraindicated. Record review of Resident #16's MDS dated [DATE] revealed a BIMS score of 7 out of 15, indicating severely impaired cognition. Section C1310 asked about signs and symptoms of delirium, and No was selected for any evidence of an acute change in mental status from baseline. Under section D for mood, Resident #16 reported he had trouble falling or staying asleep or had little energy. E0100, 676306 Page 12 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Potential Indicators of Psychosis, none of the above was selected related to hallucinations and delusions. Section I, Active Diagnoses, had non-Alzheimer's Dementia, Parkinson's, anxiety, and depression was added. N0410 had 7 days marked for antipsychotics, 0 days marked for anti-anxiety, 7 days marked for antidepressants, and 0 for hypnotics for the number of days taken prior. For N0450, Antipsychotic Medication Review, yes was selected indicating the resident had been taking antipsychotics on a routine basis. On the next question, no was selected indicating a gradual dose reduction had not been attempted, and a GDR had not been documented by a physician as clinically contraindicated. Record review of Resident #16's medical record revealed a PASRR Level 1 Screening from 6/3/22, that indicated the resident had no mental illness, no intellectual disability, and no developmental disability. Record review of Resident #16's chart revealed a medication order for Seroquel Tablet 25mg 1 PO Q12hr for hallucinations, was ordered on 10/5/22 at 6:25pm by APRN [NAME]. Record review of Resident #16's MAR on 6/8/23, revealed the resident had been taking Seroquel 25mg 1 PO Q12hr for hallucinations, since October 2022. Record review of Resident #16's Consultant Pharmacist Recommendation to Physician dated 4/24/23 by Consultant PharmD [NAME], revealed the resident had been taking Seroquel 25mg Q12hr since 10/5/22 without a GDR. The Pharmacist recommended a GDR be performed, and on 4/8/23 MD KR wrote hospice pt, leave this med as ordered. There was no rationale documented as to why a GDR would not be performed. Record review of Resident #16's medical records on 6/8/23 revealed no diagnoses documented for the indication of Seroquel, except hallucinations. Record review of Resident #16's care plan dated 5/12/23, revealed, Resident uses psychotropic medications (Antipsychotic) r/t Hallucinations. Goals: Resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Resident will reduce the use of psychoactive medication through review date. Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Monitor/record occurrence of/for target behavior symptoms, such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. and document per facility protocol. Monitor/record/report to MD PRN side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea/vomiting, behavior symptoms not usual to the person. Interview with MD KR on 6/8/23 at 11:43am, she stated she did not do GDRs on skilled nursing facility residents, or if the family requested to keep the residents on the medications. She stated that Resident #16 was investigated for other sources of hallucinations, like infection and medications, and nothing was found. She also said she took action and put residents on medication when signs of delusional behavior occurred. She admitted to not trying a GDR on Resident #16, and said she was going to attempt a GDR because Seroquel can cause problems in this population. 2. Record review of Resident #179's face sheet printed 6/8/23, indicated she was an [AGE] year-old 676306 Page 13 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some female, admitted on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness on the right side after a stroke), unspecified, aphasia following cerebral infarction (trouble swallowing after stroke), and depression (sadness/crying/hopelessness that interferes with daily activities). Record review of Resident #179's MDS, dated [DATE], revealed she came from an acute hospital. Question A1500 indicated she had no serious mental illness or ID/DD. Resident #179 had a BIMS score of 0 out of 15 indicating severely impaired cognition. C1310 indicated the resident had no change in mental status, and no problems with mood. None of the above was selected for hallucinations, and delirium. Under active diagnoses, she had listed CVA (another name for stroke), TIA (mini stroke), or stroke, hemiplegia, aphasia, and depression among others. The resident had been taking antipsychotics for the previous 3 days, no anti-anxiety's, antidepressants for the previous 3 days, and no hypnotics. Record review of Resident #179's medical record revealed an undated, New Admission/readmission Report Sheet, with information given from the previous hospital, to the facility. According to the report sheet, the resident had a diagnosis of AMS r/t UTI, lactic acidosis (a buildup of lactic acid in the blood stream and can be an indicator of severe infection) and had a cognitive status of AAOx2 (was only alert to name and place). Record review of Resident #179's medical records revealed an order for Risperidone 1mg PO BID for antipsychotic/manic, and Quetiapine Fumarate (Seroquel) 50mg PO QHS for antipsychotic agent, ordered by MD KR on 5/27/23 at 11:39pm. Record review of Resident #179's medical record revealed a progress note created by RN FF on 5/28/23 at 12:28am, indicating admission diagnoses of altered mental status r/t UTI, and lactic acidosis. Record review of Resident #179's MAR on 6/8/23, revealed the resident had been taking Risperidone 1mg PO BID and Seroquel 50mg PO QHS since admission on [DATE]. Record review of Resident #179's medical records on 6/8/23 revealed no documented diagnoses of paranoia (unrealistic distrust of others, suspicious), or psychotic delusions (unshakeable belief in something bizarre or obviously untrue) in the notes. No other indications for usage of the medications were noted as well. Record review of Resident #179's baseline care plan dated 6/1/23, revealed no documentation of psychotropic usage or mental health diagnoses. Interview with MD KR on 6/8/23 at 11:43am, she revealed she continued Resident #179's Risperidone 1mg PO BID and Seroquel 50mg PO QHS because the family requested her to do so, and the resident was taking them at the hospital. She also stated she gave the medication to Resident #179 due to paranoia, and psychotic delusions. 3. Record review of Resident #12's face sheet printed 6/8/23, indicated he is a [AGE] year-old male, admitted on [DATE], with diagnoses of adjustment disorder with mixed disturbance of emotions and conduct (short term condition in a person who experiences an exaggerated reaction to a stressful/traumatic event), malignant neoplasm of larynx (cancer of the voice box), and weakness. Record review of Resident #12's MDS dated [DATE] revealed he came from an acute care hospital and had a BIMS score of 13 out of 15 indicating normal cognition. Question A1500 indicated he had no 676306 Page 14 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0758 Level of Harm - Minimal harm or potential for actual harm serious mental illness or ID/DD. C1310 indicated the resident had no change in mental status, and no problems with mood. None of the above was selected for hallucinations, and delirium. Under Active Diagnoses, depression was not selected, nor was any other mental health diagnoses. Under section N 0 was marked for any antipsychotics being used in the previous 7 days, 0 for anti-anxiety's, and 6 for antidepressants. Residents Affected - Some Record review of Resident #12's hospital records, dated 4/27/23, revealed no diagnosis of depression or that Imipramine HCL 10mg PO QHS was given. Record review of Resident #12's medical record revealed a history and physical performed by APRN [NAME] on 5/2/23, with no mention of depression in the note or Imipramine on the resident's medication list. Record review of Resident #12's medical records revealed an order for Imipramine HCL 10mg PO QHS for depression, on 5/2/23 at 5:01pm by MD KR. Record review of Resident #12's MAR on 6/8/23, revealed the resident had been receiving Imipramine HCL 10mg PO QHS since 5/3/23. Record review of Resident #12's medical record on 6/8/23 revealed no documented diagnosis, or previous history of depression. Record review of Resident #12's care plan dated 5/17/23 stated: I use antidepressant medication r/t depression. Goals: I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: Educate me/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of antidepressant drugs. Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. Monitor/document/report to MD PRN ongoing s/sx of depression unaltered by antidepressant meds: Sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. Interview with MD KR on 6/8/23 at 11:43am, she stated Resident #12 was taking Imipramine at the hospital and she continued it. She also stated the diagnosis of depression was in the resident's medical history. She said sometimes the hospital did not pull forward all the resident's medical history from the previous admission, so diagnoses would be left out. MD KR looked up the history on her phone and said the diagnosis was mixed emotional features. She stated she had to look back a few admissions in the hospital records to find the diagnosis. Per the MD, she did not initially prescribe Imipramine, so it had to have come from the hospital. MD KR said if a resident gave her their history she documented it in her notes, and it should have been in one of the provider's notes. She also stated if a resident told her they were taking a medication previously, she continued it. Record review of the facility policy and procedure for Medication Regimen Review (Revised April 2007) read in part: Policy Interpretation and Implementation: 5. The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible.7. The Consultant Pharmacist will document his/her findings and 676306 Page 15 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some recommendations on the monthly drug/medication regimen review report. 8. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity .If the Physician does not provide a pertinent response, or the Consultant Pharmacist identifies that no action has been taken, he/she will then contact the Medical Director, or if the Medical Director is the Physician of Record, the Administrator. 9. The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions. 10. Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record. 11. The Consultant Pharmacist will submit a quarterly report that includes key summary information including: a. The status of the facility's Pharmaceutical Services b. Staff performance in complying with regulatory requirements related to medication utilization and monitoring c. Problem areas noted (documentation errors, medication errors, etc.) d. Recommended solutions to problem areas e. Follow-up reports relative to facility's corrective action to noted problems f. Key findings from medication regimen reviews and g. Other pertinent information. . 676306 Page 16 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food preparation and storage in that: -One of one commercial can opener was not kept clean and in a sanitary condition. -The facility failed to ensure that dented can good were removed from the shelve. -The facility failed to ensure expired food items were removed from the dry goods storage. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings include: Kitchen Observation and Interview on 06/08/23 between 8:30AM and 8:40AM with the Dietary Manager, revealed the following- The commercial can opener had a greasy dark substance around the cutting blade and the blade holder. The Dietary Manager said it needed to be cleaned. -one of two deep fryer in the kitchen had dark looking grease. The Dietary Manager said it needed to be cleaned out and was dirty because it was used for fish fry over the weekend. A table-top portable grill oven by the right counter table was coated with dark greasy substance (Baked on grease) in and around it. The Dietary Manager said he would order a new one. -observation of the walk-in cooler revealed a tartar source dated 05/03/23-06/03/23. The dietary Manager took it out of the walk-in cooler. Observation of the dry good storage area revealed the following food products with expiration dates: 3 boxes of Chicken and pea soup with expired date of 06/2022. 6 -8 oz Diced green paper with expired date of 03/2022. 2 carton of beignet soup with used by date 03/12/21. 5 cartons 32 oz of pineapple juice with expired date of 06/05/23. The dietary Manager took all identified expired and dented can goods out of the food pantry. Interview at the same time, the Dietary Manager said he expected all food preparation items in the kitchen to be cleaned and expired food product removed. He said he was short on staffing. He said serving expired and dented can good can lead to food poisoning. Record review of the facility policy titled Food Receiving and storage dated 2001 and revised July 2014 read in part- Foods shall be received and stored in a manner that complies with safe food handling practices. 676306 Page 17 of 18 676306 06/08/2023 Holly Hall 2000 Holly Hall St Houston, TX 77054

F 0812 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676306 Page 18 of 18