Health inspection·February 23, 2023

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 4 days reviewed for RN hours, in that: Residents Affected - Few Facility failed to make sure there was RN coverage for 4 days in the facility. This failure could place residents at risk of not receiving related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. Findings include: Record review of facility payroll- based journal for the month of February 2023 showed there was no RN coverage for the following 4 days: February 4th 2023. February 5th 2023. February 11th 2023. February 12th 2023. During an interview on 02/23/2023 at 1:15 p.m., the Administrator stated she usually tried to stretch the RN time to cover every day, but she was not able to cover all days as she would love to. She stated she did not know how this would affect the residents because she was not a clinical person. She stated they do it because the regulation required it. During an interview on 02/23/2023 at 1:15 p.m., the ADON stated it was important for the facility to have RN coverage because the RN would be available to do what was not in the scope of an LVN and Page 1 of 11 676309 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

F 0727 this failure could affect residents not to receive the adequate care/intervention they needed. Level of Harm - Minimal harm or potential for actual harm Record review of facility staffing policy dated October 2017, line number 2 reads A Registered nurse shall be available for 8 consecutive hours per day, 7 days per week. Residents Affected - Few 676309 Page 2 of 11 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

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 ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 6 residents (Resident #15), 1 of 1 medication storage rooms, and 1 of 3 medication carts, reviewed for pharmacy services in that: 1. The facility failed to order medications timely for Resident #15 which resulted in missed administration observed on 2/22/23. 2. The facility failed to ensure that expired medications were not stored with current medications in the medication storage room and the medication cart. This failure could place residents at risk for not receiving the therapeutic benefit of the medication and/or worsening health concerns. Findings included: 1. Record review of Resident # 15's face sheet dated 02/23/23 revealed a [AGE] year-old female with an admission date of 1/14/23, diagnoses included dehydration (abnormal water loss from the body), malignant neoplasm of liver (cancer of the liver), diabetes mellitus due to underlying condition with diabetic polyneuropathy (inability of the pancreas to produce insulin to bring blood sugar levels down due to another condition, with nerve pain), disease of biliary tract (problems with tubes that drain bile from the liver), pressure ulcer of sacral region, unstageable (pressure ulcer near the buttocks that is not known how deep it is), muscle wasting and atrophy (loss of muscle making them smaller and weaker), muscle weakness, cognitive communication deficit (difficulty with thinking or how someone uses language). Record review of Resident # 15's physician order summary report with start date 1/19/23 had the following medication to be given by mouth. Zinc Sulfate Tablet Give 1 tablet PO QD for supplement, to aid in wound healing. The physician order summary report also revealed an order with a start date of 2/7/23 for Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. Record review of Resident # 15's Comprehensive MDS dated [DATE] revealed a BIMS score of 06 out of 15, indicating severe impairment with her cognition. Resident #15 required limited to extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. She did not have any functional limitations with her upper or lower extremities. Resident #15 was unable to walk and used a wheelchair to get around the facility. She was always incontinent of bowel and bladder and was not on a toileting program. Resident #15 did not have trouble swallowing and was on a therapeutic diet. According to the MDS, Resident #15 had 4 unstageable pressure ulcers present on admission. Record review of Resident #15's baseline care plan with date 1/17/23, revealed she had unstageable 676309 Page 3 of 11 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pressure ulcer/pressure injury to her sacrum (tailbone) with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer/pressure injury r/t disease process cholangiocarcinoma (cancer of the bile ducts) with biliary obstruction s/p biliary stent and biliary drainage (a device to open the bile ducts to allow for drainage). Stage III to left buttocks, stage III to right buttocks and DTI to right heel. The resident's pressure ulcer/pressure injury will show signs of healing and remain free from infection by/through review date: Administer medications, supplements and/or treatments as ordered. Resident #15 had unplanned/unexpected weight loss r/t acute illness: Give the resident supplements as ordered. Alert nurse/dietician if not consuming on a routine basis. Observation and interview on 2/22/23 at 8:58 am Med Tech A revealed the medications (Zinc Sulfate and Pro Stat Oral Liquid Amino Acids-Protein Hydrolysate) were not on the medication cart and were not available to give to Resident #15 on 2/22/23. Med Tech A stated the physician ordered medications were not available to give to Resident #15 on 2/22/23 because they were back ordered from the pharmacy. Record review of Resident #15's MAR for February 2023 revealed an order Zinc Sulfate Tablet Give 1 tablet PO QD for supplement, to aid in wound healing and Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. According to February MAR, Zinc Sulfate was not administered 1 time, on 2/22/23. Pro-Stat, according to the February MAR, was not administered 5 times: 2/17/23 in the AM, 2/19/23 in the AM and PM, 2/20/23 in the AM, and 2/22/23 in the AM. Record review of clinical nurse's progress notes dated 2/17/23 at 11:08am, 2/19/23 at 11:57am, 2/19/23 at 9:13pm, 2/20/23 at 12:33pm, and 2/22/23 at 9:31am for Resident #15 revealed medication was back ordered for Pro-Stat Oral Liquid. The clinical nurses progress note dated 2/22/23 at 9:31am revealed medication was also back ordered for Zinc Sulfate. Record review of Resident #15's clinical record revealed no documentation or fax indicating the doctor was notified of the medications missed by the resident. Interview on 2/23/23 at 9:56am with LVN A stated the staff called the MD if the resident had not received the missed medication for at least 3 days, unless it was a significant medication like seizure medication then they called right away. She said the documentation of the call was in the medication administration note. LVN A stated the MD would then decide to discontinue the medication or change it depending on what the medication was and what the reason was for not having it, like insurance approval or being back ordered. LVN stated a lot of the time the reason they did not have the medication was due to insurance reasons. Interview on 2/23/23 at 10:50am with LVN B, the nurse for another hall, revealed they notified the MD the same day a medication was not available or was back ordered and not available to give to a resident. She also stated they documented the conversation in the progress note. LVN B stated they also notified pharmacy to see if it was insurance related so pharmacy could help get it resolved. Interview on 2/23/23 at 10:55am with LVN A again revealed she was aware Zinc Sulfate and Pro Stat were back ordered; however, she was not aware the Pro Stat had been back ordered for so long, and that so many doses were missed. She stated the Pro Stat should be here any day and she would check with pharmacy to find out when. LVN A stated the MD was aware the medications were back ordered; however, she was unable to find any documentation stating this. She stated she must have told the MD verbally and forgot to document it. 676309 Page 4 of 11 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/23/23 at 1:45pm with the ADON revealed she had not been made aware of Resident #15's Zinc Sulfate and Pro-Stat not being available for administration. She stated the nursing staff should have notified the physician if the medications were not available because the risk is that Resident #15's wound could get worse or stop healing. Record review of facility's Medication and Treatment Orders policy (revised July 2016) read in part: Policy Interpretation and Implementation: 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Record review of the facility's Medication Utilization and Prescribing - Clinical Protocol policy (revised May 2022) read in part: Assessment and Recognition: 6.Staff will identify significant factors that may affect medication effectiveness and medication-related problems . Cause Identification: 2.staff will evaluate the effectiveness and effects of the medications in a resident's regimen. Treatment/Management: 4. The staff .will identify and address unexpected, unintended, undesirable . responses to medication based on the severity of underlying conditions .risks of worsening medical conditions, and other factors. Record review of the facility's Administering Medications policy (Revised April 2019)) read in part: .Policy: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 8. If a .medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss concerns 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . 2. Observation on 2/23/23 at 10:41am, with ADON present, revealed the following expired medications/biologicals in the medication storage room: 676309 Page 5 of 11 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

F 0755 -1 full medium sized plastic bag of purple top vacutainers (blood collection tubes), expired on 3/31/22; Level of Harm - Minimal harm or potential for actual harm -1 full medium sized plastic bag of gold top vacutainers (blood collection tubes), expired on 11/30/21; -1 box of blue top vacutainers (95 out of 100 count blood collection tubes), expired 4/30/21; Residents Affected - Some -15 single use containers of Vial2Bag Advanced 20mm (single use fluid transfer device) for IV (intravenous) containers, expired 8/1/22; and -3 bottles of Amoxicillin and Clavulanate Potassium for Oral Suspension, USP 400mg/57mg expired 2/11/23 in the refrigerator. Further observation on 2/23/23 at 10:41am revealed a sign posted on the cabinet door under the handwashing sink that read, There is to be NO!!! Items in the cabinet underneath the sink. Inside the cabinet the surveyor observed 3 boxes of medications: 2 boxes of Budesonide inhalation suspension 0.5mg/2ml and 1 box of Ipratropium Bromide Albuterol Sulfate inhalation solution 0.5mg/3mg per 3ml. These medications were placed underneath the sink, below the water drainpipe. Interview on 02/23/23 at 10:53 am the ADON stated, expired medications should not be in the medication storage room because they would not be good. The ADON stated medications should not be placed underneath the sink because water could leak on the medications and that could be harmful to the resident. The ADON stated it is each nurses' responsibility to ensure that any medications they administer is not expired, removed for patient safety and all nurses had to follow the 5 rights of medication administration. Observation on 2/23/23 at 12:20pm, with LVN C present, revealed the following opened and expired medications in the nurse's medication cart: 2 blister packs of Hyoscyamine Sublingual 0.125mg tablets expired 2/8/23, with 1 opened. 3 blister packs of Promethazine 25mg tablets expired 2/8/23, with 1 opened. Interview on 2/23/23 at 12:25pm with LVN C stated there was not a policy or protocol on who or when to check for expired medications in the medication carts. She stated that she checked the medication carts every now and then for expired medications. LVN C stated that if expired medications are given, they could be less effective. Record review of the facility's Storage of Medications policy (Revised 2020) read in part: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary matter. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Record review of the facility's Administering Medication policy (Revised April 2019) read in part: Policy Interpretation and Implementation: 12. The expiration/beyond use date on the medication label 676309 Page 6 of 11 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

F 0755 is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676309 Page 7 of 11 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

F 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 6.9%, based on 2 errors out of 29 opportunities, which involved 1 of 6 residents (Resident #15), and 1 of 5 staff (Med Tech A) reviewed for medication errors. Residents Affected - Few Med Tech A failed to administer 2 medications (Zinc Sulfate Tablet and Pro Stat Oral Liquid Amino Acids-Protein Hydrolysate) to Resident #15 on 02/22/2023. This failure could place residents at risk for not receiving therapeutic effects of their prescribed medications and possible adverse reactions. Finding included: Record review of Resident #15's face sheet dated 02/23/23 revealed a [AGE] year-old female with an admission date of 1/14/23, diagnoses included dehydration (abnormal water loss from the body), malignant neoplasm of liver (cancer of the liver), diabetes mellitus due to underlying condition with diabetic polyneuropathy (inability of the pancreas to produce insulin to bring blood sugar levels down due to another condition, with nerve pain), disease of biliary tract (problems with tubes that drain bile from the liver), pressure ulcer of sacral region, unstageable (pressure ulcer near the buttocks that is not known how deep it is), muscle wasting and atrophy (loss of muscle making them smaller and weaker), muscle weakness, cognitive communication deficit (difficulty with thinking or how someone uses language). Record review of Resident # 15's physician order summary report with start date 1/19/23 had the following medication to be given by mouth. Zinc Sulfate Tablet Give 1 tablet PO QD for supplement, to aid in wound healing. The physician order summary report also revealed an order with a start date of 2/7/23 for Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. Record review of Resident # 15's Comprehensive MDS dated [DATE] revealed a BIMS score of 06 out of 15, indicating severe impairment with her cognition. Resident #15 required limited to extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. She did not have any functional limitations with her upper or lower extremities. Resident #15 was unable to walk and used a wheelchair to get around the facility. She was always incontinent of bowel and bladder and was not on a toileting program. Resident #15 did not have trouble swallowing and was on a therapeutic diet. According to the MDS, Resident #15 had 4 unstageable pressure ulcers present on admission. Record review of Resident #15's baseline care plan with date 1/17/23, revealed she had unstageable pressure ulcer/pressure injury to her sacrum (tailbone) with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer/pressure injury r/t disease process cholangiocarcinoma (cancer of the bile ducts) with biliary obstruction s/p biliary stent and biliary drainage (a device to open the bile ducts to allow for drainage). Stage III to left buttocks, stage III to right buttocks and DTI to right heel. The resident's pressure ulcer/pressure injury will show signs of healing and remain free from infection by/through review date: Administer medications, supplements and/or treatments as ordered. Resident #15 had 676309 Page 8 of 11 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

F 0759 Level of Harm - Minimal harm or potential for actual harm unplanned/unexpected weight loss r/t acute illness: Give the resident supplements as ordered. Alert nurse/dietician if not consuming on a routine basis. Observation on 2/22/2023 beginning at 8:58 a.m. during med pass revealed, Med Tech A prepared, dispensed, and administered 5 medications to Resident #15. The medications observed were: Residents Affected - Few 1. Senna-S 8.6-50mgmg Give 1 tablet PO BID for constipation. 2. Vitamin C 500mg Give 1 PO QD to aid in wound healing. 3. Norco 10/325mg Give 1 tablet PO BID for pain. 4. Coreg 6.25 Give 1 PO BID for high blood pressure. 5. Neurontin 300mg Give 1 PO TID for neuropathy (nerve pain). Further observation revealed Med Tech A failed to administer 2 prescribed medications. 1) Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. 2) Zinc Sulfate Tablet Give 1 PO QD for supplement, to aid in would healing. Observation and interview on 2/22/23 at 8:58 am Med Tech A revealed the medications (Zinc Sulfate Tablet and Pro Stat Oral Liquid Amino Acids-Protein Hydrolysate) were not on the medication cart and were not available to give to Resident #15. Med Tech A stated the physician ordered medications were not available to give to Resident #15 on 2/22/23 because they were back ordered from the pharmacy. Record review of Resident #15's MAR for February 2023 revealed an order Zinc Sulfate Tablet Give 1 tablet PO QD for supplement, to aid in wound healing and Pro-Stat Oral Liquid (Amino Acids-Protein Hydrolysate) Give 30ml PO BID for wound healing. According to February MAR, Zinc Sulfate was not administered 1 time, on 2/22/23. Pro-Stat, according to the February MAR, was not administered 5 times: 2/17/23 in the AM, 2/19/23 in the AM and PM, 2/20/23 in the AM, and 2/22/23 in the AM. Record review of nurse's progress notes dated 2/17/23 at 11:08am, 2/19/23 at 11:57am, 2/19/23 at 9:13pm, 2/20/23 at 12:33pm, and 2/22/23 at 9:31am for Resident #15 revealed medication was back ordered for Pro-Stat Oral Liquid. The nurse's progress note dated 2/22/23 at 9:31am revealed medication was also back ordered for Zinc Sulfate. Record review of Resident #15's nurse's notes for February 2023, revealed no documented evidence found that the doctor was notified of the missed doses on February 22, 2023, or any of the other dates in February, for the medications prescribed (Zinc Sulfate Tablet and Pro Stat Oral Liquid Amino Acids-Protein Hydrolysate). Interview on 2/23/23 at 9:56am with LVN A stated the staff called the MD if the resident had not received the missed medication for at least 3 days, unless it was a significant medication like seizure medication then they called right away. She said the documentation of the call was in the medication administration note. LVN A stated the MD would then decide to discontinue the medication or change it depending on what the medication was and what the reason was for not having it, like insurance approval or being back ordered. LVN stated a lot of the time the reason they did not have the 676309 Page 9 of 11 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

F 0759 medication was due to insurance reasons. Level of Harm - Minimal harm or potential for actual harm Interview on 2/23/23 at 10:50am with LVN B, the nurse for another hall, revealed they notified the MD the same day a medication was not available or was back ordered and not available to give to a resident. She also stated they documented the conversation in the progress note. LVN B stated they also notified pharmacy to see if it was insurance related so pharmacy could help get it resolved. Residents Affected - Few Interview on 2/23/23 at 10:55am with LVN A again revealed she was aware Zinc Sulfate and Pro Stat were back ordered; however, she was not aware the Pro Stat had been back ordered for so long, and that so many doses were missed. She stated the Pro Stat should be here any day and she would check with pharmacy to find out when. LVN A stated the MD was aware the medications were back ordered; however, she was unable to find any documentation stating this. She stated she must have told the MD verbally and forgot to document it. Interview on 02/23/23 at 1:45pm with the ADON revealed she had not been made aware of Resident #15's Zinc Sulfate and Pro-Stat not being available for administration. She stated the nursing staff should have notified the physician if the medications were not available because the risk is that Resident #15's wound could get worse or stop healing. Record review of facility's Medication and Treatment Orders policy (revised July 2016) read in part: Policy Interpretation and Implementation: 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Record review of the facility's Medication Utilization and Prescribing - Clinical Protocol policy (revised May 2022) read in part: Assessment and Recognition: 6.Staff will identify significant factors that may affect medication effectiveness and medication-related problems . Cause Identification: 2.staff will evaluate the effectiveness and effects of the medications in a resident's regimen. Treatment/Management: 4. The staff .will identify and address unexpected, unintended, undesirable . responses to medication based on the severity of underlying conditions .risks of worsening medical conditions, and other factors. Record review of the facility's Administering Medications policy (Revised April 2019) read in part: .Policy: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . 8. If a .medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss concerns 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; 676309 Page 10 of 11 676309 02/23/2023 Baywood Crossing Rehabilitation & Healthcare Cente 5020 Space Center Blvd Pasadena, TX 77505

F 0759 c. The route of administration; Level of Harm - Minimal harm or potential for actual harm d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; Residents Affected - Few f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . 676309 Page 11 of 11