Health inspection·February 8, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide or arrange services as outlined by the comprehensive care plan to meet professional standards for one (Residents #1) of 18 residents observed for medication administration. Residents Affected - Few RN A and LVN B failed to report Resident #1 was missing one hydrocodone pill during narcotic count. RN A and LVN B failed to properly document Resident #1's missing hydrocodone pill during narcotic count. The noncompliance was identified as PNC. The noncompliance began on 12/01/23 and ended on 12/11/23. The facility had corrected the noncompliance before the survey began. These failures could affect residents by placing them at risk of not having their medications available as prescribed or possible drug diversions. Findings include: Review of Resident #1's quarterly MDS assessment, dated 11/29/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: cancer, hypertension, hyponatremia (the concentration of sodium in her blood was abnormally low), hyperlipidemia (an elevated level of lipids in her blood), and depression. Her BIMS score was a 7 out of 15, which meant the resident was severely cognitively impaired. Her pain management section revealed she received a scheduled pain medication regimen. Review of the facilities Narcotic Notebooks, undated, revealed Resident #1's controlled drug receipt/record/disposition form dated 11/26/23 -12/06/23 for hydrocodone was missing. Review of the facilities in-service Medication Administration Observation Checklist, dated 08/03/23, revealed nursing staff were not educated during the in-service regarding report of missing narcotics and documenting missing narcotics. RN A did not attend the in-service. LVN B attended the in-service. Review of the facility's employee roster revealed RN A was hired on 05/30/22. LVN B was hired on 07/15/19. Review of RN A's and LVN B's disciplinary actions, undated, revealed they were in violation of inappropriate storage of controlled medication, pre-pulling multiple residents' medication, Page 1 of 6 676329 676329 02/08/2024 Continuing Care at Highland Springs 7910 Frankford Road Dallas, TX 75252

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discrepancies not immediately reported to the manager, and co-signed a wasted (disposed) pill that was not witnessed. RN A and LVN B were in-serviced regarding no pre-pulling multiple resident medications, immediately report any narcotic discrepancies immediately to the manager, and do not co-sign medication wasted (disposed) without witnessing the waste (disposal) of the medication. Observation of the facility narcotic count on 02/06/24 from 10:19 am to 10:28 am revealed there were no missing medications to report or document. Interview with LVN B on 02/05/24 at 3:48 PM and 02/08/24 at 3:34 PM was attempted and voicemails were left. Interview with RN A on 02/05/24 at 4:09 PM revealed Resident #1 was missing one hydrocodone pill during a narcotic count. RN A stated she and LVN B did not know the facility policy or procedure regarding missing narcotics. RN A stated she and LVN B falsely documented Resident #1's hydrocodone pill as wasted (disposed). New She stated she was in-serviced after receiving disciplinary action. Interview with the DON on 02/05/24 at 5:00 PM revealed she expected all nurses to report missing narcotics immediately. The DON stated RN A and LVN B should not have documented the missing hydrocodone pill as wasted. She stated she monitored nursing staff to ensure skills checks/competency by rounding and auditing narcotics. The DON stated Resident #1 might be at risk of a drug diversion. The DON stated nurses were previously in-serviced regarding reporting missing narcotics and documentation on 12/2022. Review of the facility's policy, Narcotics/Controlled Substances, dated May 2021, reflected, If the cause of the discrepancy cannot be determined and/or the count does not balance, report the matter to the nursing management on call/on duty. 676329 Page 2 of 6 676329 02/08/2024 Continuing Care at Highland Springs 7910 Frankford Road Dallas, TX 75252

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of three residents (Resident #1, #2, and #3) of 18 residents reviewed for medications and pharmacy services. The facility failed to ensure nurses were adequately counting narcotic cards and blister packs, narcotic count audits were conducted to prevent a drug diversion, and nurses were properly disposing of narcotics. Resident #1 and Resident #3 were missing narcotics. Resident #1, #2, and #3 had unexplained wasted (disposed) narcotics from May 2023 to December 2023. The noncompliance was identified as PNC. The noncompliance began on 05/16/23 and ended on 12/11/23. The facility had corrected the noncompliance before the survey began. This failure could affect residents by placing them at risk of not having their medications available as prescribed or possible drug diversions. Findings included: Review of Resident #1's quarterly MDS assessment, dated 11/29/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: cancer, hypertension, hyponatremia, hyperlipidemia , and depression. Her BIMS score was a 7 out of 15, which meant the resident was severely cognitively impaired. Her pain management section revealed she received a scheduled pain medication regimen. Review of the facilities Narcotic Notebooks, undated, revealed Resident #1's controlled drug receipt/record/disposition form dated 11/26/23 -12/06/23 for hydrocodone was missing. Review of Resident #1's November 2023 MAR, dated 11/01/23 -11/30/23, reflected she was administered Norco 10mg-325mg (one) tablet orally three times daily as ordered. Review of the facility's PIR dated 12/11/23 reflected Resident #1 was missing 12 tablets of hydrocodone from 11/26/23 - 12/06/23. Resident #1 had unexplained wasted (disposed) hydrocodone on 05/16/23, 10/08/23, and 10/10/23 . The PIR was completed by the Administrator. Resident #1's December 2023 MAR was requested on 02/07/24 and was not provided by the Administrator. Review of Resident #1's January 2024 MAR, dated 01/01/24 - 01/31/24, reflected she was administered Norco 10mg-325mg (one) tablet orally three times daily as ordered . Review of Resident #2's significant change in status MDS assessment, dated 01/19/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypertension, peripheral vascular disease, renal insufficiency, hyperlipidemia , Alzheimer's disease, non-Alzheimer's dementia, depression, and cataracts. Her BIMS score revealed she was rarely/never understood. Her pain management section revealed she received a scheduled pain medication regimen. 676329 Page 3 of 6 676329 02/08/2024 Continuing Care at Highland Springs 7910 Frankford Road Dallas, TX 75252

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of Resident #2's November 2023 MAR, dated 11/01/23 - 11/30/23, reflected she was administered Norco 5mg-325mg (one) tablet orally three times daily as ordered. Review of the facility's PIR dated 12/11/23 reflected Resident #2 had one unexplained wasted (disposed) hydrocodone pill on 11/08/23. Residents Affected - Some Review of Resident #2's face sheet dated 02/07/24 reflected she passed away on 02/06/24 at 6:40 AM. Resident #2 was receiving hospice services and passed away at the facility. Review of Resident #3's admission MDS assessment, dated 08/18/23, revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: anemia, atrial fibrillation, hypertension, peripheral vascular disease, hyperlipidemia, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, and post-traumatic stress disorder. His BIMS score was a 3 out of 15, which meant the resident was severely cognitively impaired. His pain management section revealed she received a scheduled pain medication regimen. Resident #3's August 2023 & September 2023 MAR were requested on 02/07/24 and was not provided by the Administrator. Review of Resident #3's controlled drug receipt/record/disposition forms dated August 2023 and September 2023 for hydrocodone were missing. Review of Resident #3's physician order dated 08/25/23 reflected discontinue previous narcotic orders; Norco 10/325 mg tablet by mouth every six hours. Review of Resident #3's face sheet dated 02/07/24 reflected he discharged from the facility on 10/16/23 at 11:00 AM. Review of the facility's PIR dated 12/11/23 reflected Resident #3 had one unexplained wasted (disposed) hydrocodone pill on 08/15/23. Review of the in-service titled Narcotic Count Sheet Process and Narcotic/Controlled Substance Policy Review, dated 12/28/23, revealed the facility in-serviced all nurses. Record review of the facility's provider investigation report regarding Resident #1 revealed the facility identified the failure which caused Resident #1's, #2's, and #3's drug diversion and they reported the incident to HHSC on 12/11/23. The facility also identified measures to prevent a similar occurrence, including in-servicing nurses on the medication re-order process, narcotic reconciliation process, wasted medication policy, and reporting missing narcotics to the ADON or DON. The facility added a new reconciliation sheet to ensure accurate reconciliation of all narcotics. At the time of entry by the surveyor, the facility had not fully implemented these measures as evidenced by: - in-service nurses regarding adequate way to count narcotics. - in-service nurses regarding wasting (disposal) of narcotics. - Ensure nurses were not sharing keys to the narcotic lock boxes. Interview with LVN C on 02/05/24 at 1:39 pm revealed she wasted (disposed) of narcotics by 676329 Page 4 of 6 676329 02/08/2024 Continuing Care at Highland Springs 7910 Frankford Road Dallas, TX 75252

F 0755 Level of Harm - Minimal harm or potential for actual harm discarding the pill in the sharps container or smashing the pill to rinse it down the drain. She stated during narcotic count she did not review the Disposition of Narcotic sheet/Med cards log. She stated the DON was responsible for reviewing that log. She stated she would not know if the narcotic count was inaccurate if the resident's narcotic sheet and card were missing. She was in-serviced on 12/29/23 regarding narcotic count sheet process and narcotic/controlled substance policy review. Residents Affected - Some Interview with LVN D on 02/05/24 at 1:59 pm revealed during narcotic count she did not review the Disposition of Narcotic sheet/Med cards log. She stated the DON was responsible for reviewing that log. She stated she would not know if the narcotic count was inaccurate if the resident's narcotic sheet and card were missing. Interview with LVN E on 02/05/24 at 2:47 pm revealed during narcotic count she did not review the Disposition of Narcotic sheet/Med cards log. She stated the DON was responsible for reviewing that log. She stated she would not know if the narcotic count was inaccurate if the resident's narcotic sheet and card were missing. Interview with LVN B on 02/05/24 at 3:48 PM and 02/08/24 at 3:34 PM was attempted and voicemail was left. Interview with RN A on 02/05/24 at 4:09 PM revealed Resident #1 was missing one hydrocodone pill during a narcotic count on 12/01/23. RN A stated she and LVN B did not know the facility policy or procedure regarding missing narcotics. RN A stated she and LVN B falsely documented Resident #1's hydrocodone pill as wasted (disposed) on 12/01/23. RN A stated she did not report the missing narcotic pill to the DON because she was afraid. She stated she did not receive an in-service regarding reporting and documenting missing narcotics prior to the incident. She stated the incident was not reported to the DON until 12/10/23. RN A stated she received a disciplinary action for falsifying documentation and failure to report a missing narcotic. Interview with the DON on 02/05/24 at 5:00 pm revealed on 12/10/23 RN A reported that she and LVN B failed to report Resident #1's missing hydrocodone pill during narcotics count on 12/01/23. The DON stated on 12/10/23 Resident #1's narcotics count sheet dated 11/26/23 -12/06/23 could not be located. She stated from 12/10/23 to 12/11/23 an audit was conducted of all residents receiving narcotics. She stated she discovered Resident #1 was missing 12 hydrocodone pills. The DON stated she also discovered Resident #3 (discharged ) was missing 54 tablets of hydrocodone and the corresponding narcotics sheets for August 2023 and September 2023. She stated Resident #1, #2, and #3 had unexplained wasted (disposed) narcotics from May 2023 to December 2023 by the same nurse, LVN F. She stated LVN F was terminated on 12/20/23. The DON stated the previous drug regimen required nurses to count all resident narcotic cards cumulatively on one form and count the resident's pills individually on a different form. She stated the nurses were not responsible for reviewing the start/end date of the narcotics. She stated nurses were required to place the narcotic count sheets of the discontinued and/or completed medications in the residents' chart then dispose of the narcotic cards. She stated the ADON and Clinical Manager were responsible for auditing the narcotic count sheets weekly by utilizing a medication room check sheet. She stated the ADON and Clinical Manager were not utilizing the medication room check sheet to audit the narcotic count sheets. She stated the new narcotic count included a form requiring nurses to document discontinued, completed, and new narcotics. The DON stated the nurses were required to place the narcotic count sheet of the discontinued and/or completed medications in the front of the narcotics count book then keep the narcotics card in the locked cabinet. She stated since the facility did not have an ADON or Clinical Manager, she audited the narcotics count sheets weekly. The DON stated the nurses were still required to count all resident narcotic cards 676329 Page 5 of 6 676329 02/08/2024 Continuing Care at Highland Springs 7910 Frankford Road Dallas, TX 75252

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cumulatively on one form and count the resident's pills individually on a different form. She stated nurses were in-serviced on 12/29/23 regarding narcotic count sheet process and narcotic/controlled substance policy review. She stated the nurses were still not responsible for reviewing the start/end date of the narcotics. Observation of LVN D, LVN C, and LVN E completing the facility narcotic count on 02/06/24 from 10:19 am to 10:28 am revealed the nurses did not check the Disposition of Narcotic sheet/Med cards log or the dates on the residents' individual count sheets. The nurses were checking to see if the residents' name, prescription, and number of pills matched the individual narcotic sheet and narcotic card. Review of the Disposition of Narcotic sheet/Med cards log undated revealed the following information to be completed by the nurse and reviewed by the DON; date, resident name, medication/dosage, number of tablets, number of cards received/removed, new order or refilled/new admission, medication completed, resident deceased , and medication discontinued. Record review of the facility policy, Narcotics/Controlled Substances, dated 05/2021, revealed, All discrepancies in the narcotic count are reported to the Clinical Manager/Delegating Nurse/Nurse Supervisor immediately. Record review of the facility policy, Medication Administration, Receipt, Storage & Disposal, dated 10/2023, revealed, Discontinued or expired medications shall be destroyed within 30 days or sooner per state regulation, in the facility, or if unopened and properly labeled, returned to the pharmacy per state regulation. Destruction of narcotics will be completed per state regulations/state board of pharmacy. 676329 Page 6 of 6