Health inspection·March 20, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 ensure the resident was free from misappropriation of property for 4 of 5 residents (Resident #1. CR #1, CR #3 and CR #4) reviewed for misappropriation of property. Residents Affected - Some - The facility failed to ensure that LVN A did not misappropriate CR #1's Tylenol #3 over a 3-month period (June 2023 to August 2023). - The facility failed to have a system in place to identify drug diversion of controlled substances and to take action on the pharmacist consultant's identified discrepancies during random control drug audits for Resident #1, CR #3 and CR #4 even after an alleged case of drug diversion by LVN A over a three-month period. These failure could place residents at risk for misappropriation of medications and uncontrolled pain. Findings included: CR#1 Record review of CR #1's Face Sheet dated 02/29/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: right dominant side paralysis, muscle weakness, history of falling and unspecified pain. CR #1 discharged from the facility of 08/29/23. Record review of CR#1's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, the resident reported occasional pain over the five days received that did not limit his day-to-day activities and did not make it hard to sleep. Record review of CR #1's undated Care Plan revealed, focus- the resident on pain medication therapy related to pain, 08/15/23: resident prefers to take Norco and not Tylenol #3. Intervention- when the resident requests PRN medication Norco will be administered per MD order and not Tylenol #3. Record review of CR #1's Physician's Order dated 06/11/23 revealed, Tylenol with Codeine #3- 1 tablet every 6 hours as needed for pain scale 4-7. Record review of CR #1's Physician's Progress Note dated 06/14/23 revealed, date of service 06/12/23, I have changed his Tylenol Codeine to Norco 7.5 mg, continue with muscle relaxants and Neurontin [medication for nerve pain] as tolerated. Page 1 of 31 676420 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of CR #1's Progress Note dated 06/14/24 signed by RN A revealed, OT reported CR #1 was in a lot of pain and needed something for pain, but the resident had been offered pain medications all morning but kept refusing it. CR #1 said he did not want narcotics but accepted Ibuprofen and Bio freeze (a topical used to treat pain). Record review of CR #1's Tylenol #3 Controlled Drug Record started 06/11/23 revealed, LVN A signed out 11 of the 15 doses documented as administered/retrieved. - 06/11/23 at 01:00 PM by LVN C - 06/11/23 at 09:00 PM by RN B - 06/22/23- LVN A documented a pill was documented on the floor of the cart resulting in a total of 27 pills. There was no second nurse signature. - 07/02/23- a dose was dispensed; the time of administration was illegible. - 07/02/23 at 12:00 AM a dose was dispensed by LVNA. - 07/06/23 at 01:00 AM a dose was dispensed by LVNA. - 07/15/23 at 09:00 PM a dose was dispensed by LVNA. - 07/24/23 at 06:51 PM a dose was dispensed by RN C. - 07/30/23 at 02:00 AM a dose was dispensed by LVNA. - 07/30/23 at 07:26 PM a dose was dispensed by LVNA. - 08/03/23 at 12:00 AM a dose was dispensed by LVNA. - 08/03/23 at 08:15 AM a dose was dispensed by LVNA. - 08/07/23 at an illegible time a dose was dispensed by LVN A. - 08/13/23 at 08:16 PM a dose was dispensed by LVNA. - 08/13/23 at 06:58 PM a dose was dispensed by LVNA. This dose was documented out of time order. Record review of CR #1's July 2023 MAR revealed, only 2 of the 6 doses signed out by LVN A on CR #1's Control Log for Tylenol #3 were documented. - doses on 07/15/23 at 09:00 PM and 07/30/23 at 07:26 PM were signed on the MAR by LVN A. - 2 doses on 07/02/23, 1 dose on 07/23 at 01:00 AM and 1 dose on 07/30/23 at 02:00 AM were not documented in the MAR. Record review of CR #1's August 2023 MAR revealed, 4 of the 5 doses signed out by LVN A on CR #1's Control Log for Tylenol #3 were documented. 676420 Page 2 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0602 - 08/03/23 at 12:00 AM a dose was dispensed by LVNA. Level of Harm - Minimal harm or potential for actual harm - 08/07/23 at 08:00 PM a dose was dispensed by LVN A. - 08/12/23 at 08:16 PM a dose was dispensed by LVNA. Residents Affected - Some - 08/13/23 at 06:58 PM a dose was dispensed by LVNA - the dose on 08/03/23 at 08:15 AM dose documented in the control log was not documented in the MAR. Record review of the facility provided undated and unsigned investigation summary revealed: - CR #1 stated he did not like Tylenol #3 and only wanted to take Norco. - Interview with multiple staff revealed, that CR #1 only asked for Norco and interviews were completed on different rotations and shifts. - LVN A said she only gave CR #1 Tylenol #3 at the residents request but documentation showed she also gave the resident Norco on multiple occasions across multiple shifts. - Investigation revealed only 2 out of 7 doses signed out by LVN A on the control log were documented in [EMR] (in July 2023) for Tylenol #3 and 3 out of 8 administrations were documented for LVN's administration of Norco. This is unusual because all other medication is consistently documented in [EMR]. - LVN A was escorted to a third-party vendor to perform a urine drug test which she avoided with the excuse of past trauma. - on 08/13/23 LVN A was witnessed cornering RN C asking her to waste a narcotic but MA A intervened. - CR #1's MD stated that the resident said that Tylenol #3 did not work. There was no documentation of a facility wide audit of control substances, no documentation of interviews with other staff and no documentation of interviews with other residents. Record review of an undated interview of CR #1 revealed, CR #1 said he took Norco, and he did not take Codeine because when he took it, he did not like it and he was concerned it could be addictive. CR #1 stated that when he was admitted to the facility, he told the nurse he did not want to take Tylenol #3. CR #3 Record review of CR #3's Face Sheet dated 02/29/24 revealed, a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of: muscle weakness and pain in an unspecified joint. The resident discharged on 06/13/23. Record review of CR #3's admission MDS dated [DATE] revealed, intact cognition indicated by a BIMS 676420 Page 3 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0602 score of 15 out of 15, frequent pain that made it hard for him to sleep and limited his day to day activities. Level of Harm - Minimal harm or potential for actual harm Record review of CR #3's undated Care Plan revealed, focus- risk of pain r/t arthritis and abdominal bacterial skin infection; intervention- administer pain medication as ordered. Residents Affected - Some Record review of CR #3's Order Summary Report dated 02/29/24 revealed, Hydrocodone- Acetaminophen 10-325 mg- t tablet every 4 hours as needed for pain ordered on 06/02/23. Record Review of the Control Substance Random Audit dated 06/07/23 signed by the pharmacist consultant revealed, 3 residents were randomly audited and discrepancies of doses initialed on the MAR that are signed out on the count sheet? were observed for CR #3's Norco 10 mg for doses on 06/05/23 and 06/06/23. CR #4 Record review of CR #4's Face Sheet dated 03/20/24 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: muscle wasting, slurred speech, difficulty swallowing, dementia, congestive heart failure, high blood pressure, heartburn, history of falling and hip fracture. Record review of CR #4's admission MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, receipt of PRN pain medication, with rare pain that had no/rare impact on his ability to sleep and ability to complete therapy activities or day-to-day activities. CR #2 reported his worst pain level over the last 5 days at 06 out of 10. Record review of CR #4's undated Care Plan revealed, focus-acute pain; intervention- administer pain medications as ordered. Record review of CR #4's Physician Order dated 10/27/23 revealed, Hydrocodone-Acetaminophen 5/325 mg (Norco)- give 1 tablet via G-tube every 12 hours as needed for pain 07 out of 10. Record Review of the Control Substance Random Audit dated 11/16/23 signed by the pharmacist consultant revealed, 3 residents were randomly audited and a discrepancy of unclear count sheet documentation and doses initialed on the MAR that are signed out on the count sheet? were observed for CR #4's Norco 5mg for a dose on 11/10/23 and a quantity change without a date or signature on the count sheet that might have indicated an additional administered dose on 11/06/23. Resident #1 Record review of Resident #1's Face Sheet dated 02/29/24 revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: muscle weakness and muscle wasting. There was no documented diagnosis of anxiety. Record review of Resident #1's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, and no use of antianxiety medication documented. Record review of Resident #1's undated Care Plan revealed, no documented focus area addressing anxiety. 676420 Page 4 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #1's Physician's Orders dated 12/03/23 revealed, Alprazolam 0.25 mg- 2 tablets every 12 hours PRN anxiety. Record Review of the Control Substance Random Audit dated 12/08/23 signed by the pharmacist consultant revealed, 3 residents were randomly audited and a discrepancy of doses initialed on the MAR that are signed out on the count sheet? were observed for Resident #1's Xanax 0.25 mg (an antianxiety medication) on 12/03/23. In an interview on 02/27/24 at 02:10 PM, DON B said she had only been the DON for a month but she was previously the ADON under DON A. She said in August of 2023 MA A brought LVN A's suspected diversion to DON A's attention and once notified DON A looked into all control medications administered that day but the investigation was expanded to identify any other potential cases of drug diversion. DON B said she was not currently auditing the facility control logs, or resident MARs for potential diversion but it was her plan to start auditing the facility's controlled substances. In an interview on 02/27/24 at 02:21 PM the Chief Clinical Officer said to her knowledge DON A only performed a cart audit of the facility's controlled substances. She said he did not perform a complete audit of all residents and he did not audit the resident's MARs comparing them to the control log to identify any further diversion or other residents that might have been impacted by LVN A's suspected diversion. The Chief Clinical Officer said to her knowledge there was no evidence of control audits completed by DON A or any other DON but the pharmacist did perform random audits. In an interview on 02/29/24 at 10:45 AM, the Administrator said he was the facility abuse coordinator and he was responsible for investigations into alleged abuse, neglect or misappropriation. When asked who is responsible for ensuring nursing related investigations are thorough and complete he said the DON/or designees was and he was just responsible for pulling that information together. The Administrator said the drug diversion investigation was completed by DON A who he trusted to complete the investigation at the time. He said he did not honestly have any other information regarding the drug diversion case. The Administrator said no evidence of additional interviews or controlled drug audits completed as a result of the alleged drug diversion. He could not say how the facility responded to the identified concerns in the Pharmacist Consultant control log audits that were completed during and after LVN A's tenure at the facility since it was the DON/Designees responsibility. The Administrator could not state if the allegation of drug diversion by LVN A was confirmed even though the police were notified. The Administrator said failure to thoroughly investigate drug diversion cold place residents at risk for misappropriation. In an interview on 02/29/24 at 12:05 PM, DON B said when drug diversion is suspected the DON is expected to start a thorough investigation. The investigation should start off with any residents potentially impacted by the alleged perpetrator and then expand to all controls in the building. She said an audit should be performed inspecting/counting the actual controls and verifying them against the documentation ( control log and the MAR) to identify any discrepancies. DON B said when alerted of any discrepancies during the pharmacist control audit the expectation is that the facility initiate an investigation to identify any issues like inadequate documentation or drug diversion. She said she did not have any evidence DON A followed up on any of the Pharmacist Consultants identified discrepancies, completed a facility wide control audit or a thorough investigation into LVN A's alleged drug diversion. DON B said failure to take action on discrepancies identified in random control drug audits and failure to thoroughly investigate allegations of drug diversion could place residents at risk for further misappropriation and decline in health due to missed pain meds. 676420 Page 5 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview of 02/29/24 at 02:05 PM, when asked about what action was taken regarding any discrepancies identified in the Pharmacists Random Control Audit the Administrator said I absolutely read it. He would not provide any information regarding the required action's following the Pharmacists control drug audits. In an interview on 02/29/24 at 01:20 PM, the Pharmacist Consultant said as part of his monthly tasks he randomly selected 3 residents to ensure their control count was correct, that there was no evidence of borrowing and to ensure the control log matched the MAR. He said he notifies the facility of any identified discrepancies but is not required to follow up with the facility if action was taken, that it was the facilities responsibility to address his findings. The Pharmacist Consultant said he had not been informed by the facility of a suspicion of drug diversion in August of 2023 and he had not completed any large-scale audits for drug diversion outside of his random audits. In an interview on 02/29/24 at 04:19 PM, MA A said CR #1 was a nice man who did not really want to take pain medications, rarely received them, and felt the Tylenol #3 and Norco were messing him up so he only took them when he needed them. MA A said after reviewing CR #1's Tylenol #3 control log it appeared that majority of the doses administered were by LVN A, the signature on the control log differed from her regular signature and appeared to be a c with a squiggly line almost in an effort to hide her identity. MA A said on an unknown day in August of 2023 he observed LVN A, who worked on the 1st floor, attempted to convince an unknown nurse on the 2nd floor to take Hydrocodone- Acetaminophen (Norco) from one of the second floor residents for administration to a 1st floor resident. He said the nurses in corroboration planned to document the pill retrieved as wasted because it fell on the floor but he interjected and told LVN A that it was against facility rules and it would not be done, so LVN A returned to the 1st floor. MA A said he immediately reported LVN A's attempt to misappropriate a resident's controlled medication to DON A. He said DON A was responsible for the investigation and he did not know any specifics except for the fact that DON A attempted to test LVN A for drugs but it was unsuccessful. MA A said he did not know if the facility audited all controlled medications in the building and he did not witness any audits of controls being performed but after the incident the facility held in-services on documentation in the EMR. Record review of LVN A's Disciplinary Record dated 08/21/23 revealed, type of violation- suspicion of drug diversion; date of violation- July & August 2023; time: several. Reason for action- investigation of LVN A's routine administration of scheduled Tylenol #3 revealed she was the only one to administer the medication when CR #1 reported he never received it in the facility. LVN A would not complete a urinalysis and was removed from the schedule. Record review of the facility in-service document completed on 08/24/23 revealed . 3- recognizing signs of drug diversion: multiple narcotic sign outs on the narcotic sheet when the patient is known not to request or take very many narcotics, multiple documentation of narcotic wastage on the narcotic sheet by one nurse. 4- Preventative Measures: conducting regular audits and inspections to identify any discrepancies. Record review of the undated Administrators Job Description revealed, maintains operations by ensuring compliance with all appropriate internal policies and procedure and with external regulatory and accrediting agencies. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, 2- the DON supervises and directs all personnel who administer medications and have related functions. 676420 Page 6 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0602 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy titled Identifying Exploitation, Theft and Misappropriation of Resident Property revised 04/2021 revealed, 4- misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 5- examples of misappropriation of resident property include: f- drug diversion (taking the resident's medication). Residents Affected - Some Record review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 09/2022 revealed, 5- Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews staff members, h. interviews other residents to whom the accused employee provides care or services; i. reviews all events leading up to the alleged incident; and j. documents the investigation completely and thoroughly. 676420 Page 7 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0610 Respond appropriately to all alleged violations. 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 thoroughly investigate and to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action must be taken for 1 of 5 Residents (CR #1) reviewed for misappropriation of property. Residents Affected - Some - The facility failed to thoroughly investigate allegations of misappropriation and ensure corrective actions were in place to ensure there was no further misappropriation of control substances after LVN A was identified for misappropriating CR #1's Tylenol #3 over a period of 3 months (June through August of 2023). This failures could place residents at risk of misappropriation of residents property Findings included: Record review of CR #1's Face Sheet dated 02/29/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: right dominant side paralysis, muscle weakness, history of falling and unspecified pain. CR #1 discharged from the facility of 08/29/23. Record review of CR#1's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, the resident reported occasional pain over the five days received that did not limit his day to day activities and did not make it hard to sleep. Record review of CR #1's undated Care Plan revealed, focus- the resident on pain medication therapy related to pain, 08/15/23: resident prefers to take Norco and not Tylenol #3. Intervention- when the resident requests PRN medication Norco will be administered per MD order and not Tylenol #3. Record review of CR #1's Physician's Order dated 06/11/23 revealed, Tylenol with Codeine #3- 1 tablet every 6 hours as needed for pain scale 4-7. Record review of CR #1's Physician's Progress Note dated 06/14/23 revealed, date of service 06/12/23, I have changed his Tylenol Codeine to Norco 7.5 mg, continue with muscle relaxants and Neurontin [medication for nerve pain] as tolerated. Record review of CR #1's Progress Note dated 06/14/24 signed by RN A revealed, OT reported CR #1 was in a lot of pain and needed something for pain but the resident had been offered pain medications all morning but kept refusing it. CR #1 said he did not want narcotics but accepted Ibuprofen and Bio freeze (a topical used to treat pain). Record review of CR #1's Tylenol #3 Controlled Drug Record started 06/11/23 revealed, LVN A signed out 11 of the 15 doses documented as administered/retrieved. - 06/11/23 at 01:00 PM by LVN C - 06/11/23 at 09:00 PM by RN B - 06/22/23- LVN A documented a pill was documented on the floor of the cart resulting in a total of 27 pills. There was no second nurse signature 676420 Page 8 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0610 - 07/02/23- a dose was dispensed, the time of administration was illegible. Level of Harm - Minimal harm or potential for actual harm - 07/02/23 at 12:00 AM a dose was dispensed by LVNA. - 07/06/23 at 01:00 AM a dose was dispensed by LVNA. Residents Affected - Some - 07/15/23 at 09:00 PM a dose was dispensed by LVNA. - 07/24/23 at 06:51 PM a dose was dispensed by RN C. - 07/30/23 at 02:00 AM a dose was dispensed by LVNA. - 07/30/23 at 07:26 PM a dose was dispensed by LVNA. - 08/03/23 at 12:00 AM a dose was dispensed by LVNA. - 08/03/23 at 08:15 AM a dose was dispensed by LVNA. - 08/07/23 at an illegible time a dose was dispensed by LVN A. - 08/13/23 at 08:16 PM a dose was dispensed by LVNA. - 08/13/23 at 06:58 PM a dose was dispensed by LVNA. This dose was documented out of time order. Record review of CR #1's July 2023 MAR revealed, only 2 of the 6 doses signed out by LVN A on CR #1's Control Log for Tylenol #3 were documented. - doses on 07/15/23 at 09:00 PM and 07/30/23 at 07:26 PM were signed on the MAR by LVN A. - 2 doses on 07/02/23, 1 dose on 07/23 at 01:00 AM and 1 dose on 07/30/23 at 02:00 AM that were documented in the control log were not documented in the MAR. Record review of CR #1's August 2023 MAR revealed, 4 of the 5 doses signed out by LVN A on CR #1's Control Log for Tylenol #3 were documented. - 08/03/23 at 12:00 AM a dose was dispensed by LVNA. - 08/07/23 at 08:00 PM a dose was dispensed by LVN A. - 08/12/23 at 08:16 PM a dose was dispensed by LVNA. - 08/13/23 at 06:58 PM a dose was dispensed by LVNA - the dose on 08/03/23 at 08:15 AM dose documented in the control log was not documented in the MAR. Record review of an undated and unsigned interview of CR #1 revealed, CR #1 said he took Norco and he did not take Codeine because when he took it he did not like it and he was concerned it could be addictive. CR #1 stated that when he was admitted to the facility he told the nurse he did not want 676420 Page 9 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0610 to take Tylenol #3. Level of Harm - Minimal harm or potential for actual harm Record review of the facility provided undated and unsigned investigation summary revealed: - CR #1 stated he did not like Tylenol #3 and only wanted to take Norco. Residents Affected - Some - Interview with multiple staff revealed, that CR #1 only asked for Norco and interviews were completed on different rotations, and shift. - LVN A said she only gave CR #1 Tylenol #3 at the residents request but documentation showed she also gave the resident Norco on multiple occasions across multiple shift. - Investigation revealed only 2 out of 7 doses signed out by LVN A on the control log were documented in PCC (in July) for Tylenol #3 and 3 out of 8 administrations were documented for LVN's administration of Norco. This is unusual because all other medication is consistently documented in [EMR]. - LVN A was escorted to a third-party vendor to perform a urine drug test which she avoided with the excuse of past trauma. - on 08/13/23 LVN A was witnessed cornering RN C asking her to waste a narcotic but MA A intervened. - CR #1's MD stated that the resident said that Tylenol #3 did not work. There was no documentation of a facility wide audit of control substances, no documentation of interviews with other staff and no documentation of interviews with other residents. In an interview on 02/27/24 at 02:10 PM, DON B said she had been the DON for 1 month but she was previously the ADON under DON A. She said in August of 2023 MA A brought LVN A's suspected diversion to DON A's attention and once notified DON A looked into all control medications administered that day but the investigation was expanded to identify any other potential cases of drug diversion. DON B said she was not currently auditing the facility control logs, or resident MARs for potential diversion but it was her plan to start auditing the facility's controlled substances. In an interview on 02/27/24 at 02:21 PM the Chief Clinical Officer said to her knowledge DON A only performed a cart audit of the facility's controlled substances. She said he did not perform a complete audit of all residents and he did not audit the resident's MARs comparing them to the control log to identify any further diversion or other residents that might have been impacted by LVN A's suspected diversion. The Chief Clinical Officer said to her knowledge there was no evidence of control audits completed by DON A or any other DON but the pharmacist did perform random audits. In an interview on 02/29/24 at 10:45 AM, the Administrator said he was the facility abuse coordinator and he was responsible for investigations into alleged abuse, neglect or misappropriation. When asked who is responsible for ensuring nursing related investigations are thorough and complete he said the DON/or designees was and he was just responsible for pulling that information together. The Administrator said the drug diversion investigation was completed by DON A who he trusted to complete the investigation at the time. He said he did not honestly have any other information regarding the drug diversion case. The Administrator said no evidence of additional interviews or controlled drug audits completed as a result of the alleged drug diversion. He could not say how the facility 676420 Page 10 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0610 Level of Harm - Minimal harm or potential for actual harm responded to the identified concerns in the Pharmacist Consultant control log audits that were completed during and after LVN A's tenure at the facility since it was the DON/Designees responsibility. The Administrator could not state if the allegation of drug diversion by LVN A was confirmed even though the police were notified. The Administrator said failure to thoroughly investigate drug diversion cold place residents at risk for misappropriation. Residents Affected - Some In an interview on 02/29/24 at 12:05 PM, DON B said when drug diversion is suspected the DON is expected to start a thorough investigation. The investigation should start off with any residents potentially impacted by the alleged perpetrator and then expand to all controls in the building. She said an audit should be performed inspecting/counting the actual controls and verifying them against the documentation ( control log and the MAR) to identify any discrepancies. DON B said when alerted of any discrepancies during the pharmacist control audit the expectation is that the facility initiate an investigation to identify any issues like inadequate documentation or drug diversion. She said she did not have any evidence DON A followed up on any of the Pharmacist Consultants identified discrepancies, completed a facility wide control audit or a thorough investigation into LVN A's alleged drug diversion. DON B said failure to take action on discrepancies identified in random control drug audits and failure to thoroughly investigate allegations of drug diversion could place residents at risk for further misappropriation and decline in health due to missed pain medications. In an interview on 02/29/24 at 01:20 PM, the Pharmacist Consultant said in his monthly tasks he randomly selected 3 residents to ensure their control count was correct, that there was no evidence of borrowing and to ensure the control log matched the MAR. He said he notifies the facility of any identified discrepancies but is not required to follow up with the facility if action was taken, that it was the facilities responsibility to address his findings. The Pharmacist Consultant said he had not been informed by the facility of a suspicion of drug diversion in August of 2023 and he had not completed any large-scale audits for drug diversion outside of his random audits. In an interview on 02/29/24 at 04:19 PM, MA A said CR #1 was a nice man who did not really want to take pain medications, rarely received them, and felt the Tylenol #3 and Norco were messing him up so he only took them when he needed them. MA A said after reviewing CR #1's Tylenol #3 control log it appeared that majority of the doses administered were by LVN A, the signature on the control log differed from her regular signature and appeared to be a c with a squiggly line almost in an effort to hide her identity. MA A said on an unknown day in August of 2023 he observed LVN A, who worked on the 1st floor, attempted to convince an unknown nurse on the 2nd floor to take Hydrocodone- Acetaminophen (Norco) from one of the second floor residents for administration to a 1st floor resident. He said the nurses in corroboration planned to document the pill retrieved as wasted because it fell on the floor but he interjected and told LVN A that it was against facility rules and it would not be done, so LVN A returned to the 1st floor. MA A said he immediately reported LVN A's attempt to misappropriate a resident's controlled medication to DON A. He said DON A was responsible for the investigation and he did not know any specifics except for the fact that DON A attempted to test LVN A for drugs but it was unsuccessful. MA A said he did not know if the facility audited all controls in the building and he did not see any audits of controls being performed but after the incident the facility held in-services on documentation in the EMR. Record review of LVN A's Disciplinary Record dated 08/21/23 revealed, type of violation- suspicion of drug diversion; date of violation- July & August 2023; time: several. Reason for action- investigation of LVN A's routine administration of scheduled Tylenol #3 revealed she was the only one to administer the medication when CR #1 reported he never received it in the facility. LVN A would not complete a urinalysis and was removed from the schedule. 676420 Page 11 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility in-service document completed on 08/24/23 revealed, 3- recognizing signs of drug diversion: multiple narcotic sign outs on the narcotic sheet when the patient is known not to request or take very many narcotics, multiple documentation of narcotic wastage on the narcotic sheet by one nurse. 4- Preventative Measures: conducting regular audits and inspections to identify any discrepancies. Record review of the undated Administrators Job Description revealed, maintains operations by ensuring compliance with all appropriate internal policies and procedure and with external regulatory and accrediting agencies. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, 2- the DON supervises and directs all personnel who administer medications and have related functions. Record review of the facility policy titled Identifying Exploitation, Theft and Misappropriation of Resident Property revised 04/2021 revealed, 4- misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 5- examples of misappropriation of resident property include: f- drug diversion (taking the resident's medication). Record review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 09/2022 revealed, 5- Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews staff members, h. interviews other residents to whom the accused employee provides care or services; i. reviews all events leading up to the alleged incident; and j. documents the investigation completely and thoroughly. 676420 Page 12 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 ensure residents were free from accidents for 1 of 12 residents (CR #2) reviewed for accidents hazards. Residents Affected - Few - The facility failed to complete neurological checks per the facility policy when CR #2 had an unwitnessed fall on 11/24/23 after the initial 30 minutes following the fall. - The facility failed to complete neurological checks per the facility policy when CR #2 had an unwitnessed fall on 11/26/23 after the initial assessment until discharge to the hospital after a fall that resulted in head injury with brief loss of consciousness, small intra cranial bleed, hematoma, laceration and hospitalization. These failures could place residents at risk for unidentified changes in condition, decline in health and hospitalization. Findings included: Record review of CR #2's Face Sheet dated 02/29/24 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: hypertension and muscle wasting. The resident was transferred to the hospital on [DATE]. Record review of CR #2's undated Care Plan revealed, focus- risk for falls r/t muscle wasting, history of falls; intervention- if fall occurs initiate frequent neuro and bleeding evaluation per facility policy. Record review of CR #2's EMR revealed, the MDS was yet to be completed because the resident was a new admission. Record review of CR #2's Clinical Assessments revealed: - CR #2's neuros were only documented twice on 11/24/23, and no neuros were performed on 11/25/23 or 11/26/23. Record review of CR #2's EMR revealed, no additional neurological checks uploaded except for dose found under the clinical assessments. Record review of CR #2's Fall Risk Evaluation dated 11/24/23 at 05:45 PM revealed, CR #2 had a history of falls in the past 3 months. CR #2's predisposing factors for falls included: his gait/balance, use of an assistive device, and medication used. His fall risk score was calculated as 11 indicating a moderate fall risk. Record review of CR #2's Progress Notes dated 11/24/23 at 08:00 PM signed by LVN D revealed CR #2 had an unwitnessed fall in his room. The cause of the fall was not evident, and the resident hit his head, but the fall did not result in an ER visit. CR #2's MD was notified, and no new orders were received. Record review of CR #2's Neurological Checklist dated 11/24/23 at 08:15 PM signed by LVN D 676420 Page 13 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed, CR #2 was not oriented to time was confused, had normal pupil responses and ROM and a pain score of 06 out of 10. Record review of CR #2's Neurological Checklist dated 11/24/23 at 08:30 PM signed by LVN D revealed, CR #2 was not oriented to time, had normal pupil responses and ROM and a pain score of 04 out of 10. CR #2 had not complaints of any pain, dizziness, nausea or vomiting. Record review of CR #2's Clinical Assessments revealed, no neurological checks documented after 11/24/23 at 08:30 PM. Record review of CR #2's Progress Notes from 11/24/23 to 11/26/23 revealed, no documented interventions between CR #2's falls on 11/24/23 and 11/26/23. Record review of CR #2's Provider Note dated 11/26/23 at 01:40 PM, Per nurse, the patient had fall on 1st day of admit [11/24/23]. The resident was A&O X 3 and able to move all extremities. Record review of CR #2's Progress Notes dated 11/26/23 at 08:00 PM signed by LVN D revealed, CR #2 had an unwitnessed fall in his bathroom., He was found of the floor of the bathroom with blood coming out of his head. Record review of CR #2's Activity Participation Note dated 11/26/23 signed by LVN D revealed: - 08:00 PM CR #2 was found on the floor of the bathroom shower. There was blood all over the bathroom with further investigation there was a laceration approximal 1.5 inches in the back of his head. - 08:15 PM Patient was assisted off floor of the bathroom to his wheelchair for further assessment. Wound was cleaned and measured for size and damage. Neuro checks were performed and vital signs were taken all WNL. - 09:00 PM 911 was called, NP had a message left for her since there was no answer. CR #2's family member was called and informed of the incident and which hospital we were sending the patient. She advised that she would meet him at the ER. Record review of CR #2's Hospital EMS record dated 11/26/23 revealed: the facility called in the incident on 11/26/23 at 08:43 PM, the ambulance was notified, dispatched and enroute at 08:45 PM, the ambulance arrived on the scene at 08:47 PM, arrived at CR #2 at 08:54 PM, departed the facility with CR #2 at 09:00 PM and arrived at the hospital at 09:12 PM. The EMS staff arrived to the facility and found CR #2 sitting in a wheelchair by the nursing station waiting for transport to the hospital and CR #2 said he lost his footing while going to the bathroom and fell to the ground where he struck the back of his head. CR #2 had a 1 inch long laceration to the back of his head and his bleeding was controlled by CR #2 with a towel. Record review of CR #2's E-interact Transfer Form dated 11/26/23 at 09:30 PM by LVN B revealed, CR #2 was transferred to the hospital on [DATE] at 09:30 PM. Review of CR #2's Clinical Assessments revealed, no neurological checks documented on 11/26/24. 676420 Page 14 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility provided Discharge summary dated [DATE] revealed, CR #2 admitted to the hospital on [DATE] and discharged on 11/29/23 with diagnoses of: head injury with brief loss of consciousness, small intra cranial blead, scalp hematoma and laceration. In an interview on 02/29/24 at 08:49 AM, DON B said when a resident has an unwitnessed fall nursing staff are expected to assess the resident for injuries, changes in ROM and pain from baseline as well as performing neurological checks. She said if the resident suffered from a bleeding head injury the nurse must take measures to stop the bleeding and must likely call 911, send out notifications and then completed the required documentation. DON B said 911 comes promptly but while awaiting transfer to the hospital nursing staff must still provide care to the resident until they are transported out. She said after reviewing CR #2's file they identified that nursing staff failed to complete neuro checks on the resident following the fall on 11/24/23 and 11/26/23. DON B said if neuro checks were performed on CR #2 correctly on 11/24/23 not just the 2 15 minute checks the resident would have still been receiving neurological checks on 11/26/23 when he suffered the second fall. DON B said the purpose of performing neuro checks after unwitnessed falls or head injuries was to identify any potential brain injuries/bleeds and failure to complete neuro checks as ordered could result in a delayed identification of a change in condition that could result in seizures and/or hospitalization. DON B said she did not know what particular corrective action/investigation was completed regarding CR #2's fall because DON A was the DON at the time of the fall. In an interview on 02/29/24 at 12:05 PM, DON B said that following a fall the DON and ADON should be notified and investigation into the fall should start on the next working day. She said the DON was expected to start reviewing that the fall risk management, pain assessments, notifications, skin assessments and neurological checks were either completed or initiated. DON B said the DON must ensure that all documentation was completed with specific details including a change of condition and transfer documentation if necessary. She said following a fall nursing staff are expected to monitor the residents for 72 hours. DON B said failure to report a fall could result in failure to investigate the fall, while failure to assess residents appropriately after a fall could result in an unidentified change of condition, continued delay in treatment and failure to investigate a fall could result in continued falls and change of condition. In an interview on 02/29/24 at 01:19 PM, DON B said the facility did not complete nurse assessments for the fall protocol and it was part of nurse onboarding. A request was made by the surveyor for in-service training records for LVN D addressing the facility's fall protocol but DON B could not provide evidence of LVN D's onboarding or in-service training records on the facility fall protocol prior to exit. In an interview on 03/15/24 at 01:27 PM, LVN D said on 11/24/23 CR #2 apparently slid out of his wheelchair trying to get into the chair. She said the resident was assessed and was found to have no bruising, injuries, skin intact and no evidence of injury. LVN D said the resident was not hurt and did not hit his head per his statement but she initiated neuro checks and notified the MD. She said the MD (not specified) said neuro checks only had to be done every 4 hours since the resident was not injured and was able to verbalize that he did not hit his head. LVN D said after the first fall staff ensured that CR #2's bed was in the lowest position and fall mats were placed by his bed. She said the resident did not like the feeling of the mats on his feet so it kept him from getting out of bed unassisted. LVN D said the facility staff checked on him frequently but she did not document that he was being monitored. She said on 11/26/23 she saw the resident at 07:30 PM sitting in his wheelchair watching television in his room and at approximately 08:00 PM the resident was found on the floor in the bathroom. LVN D said she assessed the resident , started neuro checks at 08:15 PM and the 676420 Page 15 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few EMS arrived at approximately 08:30 PM. She said once the EMS arrived she handed off the resident and the EMS were on sight for 20-25 minutes prior to leaving for the hospital. LVN D she might have not documented all CR #2's neuro checks but they were done and she was working to improve her documentation. LVN D said she should have done a better job on her documentation. In an interview on 03/15/24 at 04:30 PM, DON B said CR #2 had a BIMS score of 15, was asked not to go to the bathroom on his own but he did it anyway. She said the resident could make his own decisions and both falls occurred in the bathroom when the resident went by himself. DON B said she asked the CNA about the falls but the CNA did not remember because the falls occurred many months ago and the resident was only there for a few days. In an interview on 03/18/24 at 10:30 AM, Family Member #1 said CR #2 was having trouble with his balance which is why he went to the facility for physical therapy. She said when the resident was at the facility, he got up during the night to go to the bathroom and fell so he was hospitalized . Family Member #1 said after the hospitalization the resident was moved to a facility closer to home in which he had an alarm placed on him to notify staff when he tried to get up. She said CR #2 was doing well now and was receiving PT three times a day. In an interview on 03/18/24 at 01:04 PM, DON C said she was the interim DON between DON A and DON B when CR #2 had his fall in 11/2023. She said all new residents received a fall assessment and all new admissions are considered a high fall risk due to the change in environment. DON C said residents who are considered to be at high risk for falls have their call light as well as all necessities placed within reach and nursing staff round on them every 2 hours. She said rounding every 2 hours was a standard protocol upon admission and it did not require an order documented the EMR. DON C said after a resident falls nursing staff are expected to assess the resident for injuries, check vitals, complete a post fall risk evaluation and then notify the family, the resident's physician and nursing administration. She said if the resident's fall was unwitnessed then neuro checks must be performed following the facility protocol at set intervals for 72 hours, these checks should be documented in the EMR or on paper and the information about the fall should be communicated during shift change and entered into the 24 hour report DON C said CR #2 admitted into the facility on Thanksgiving weekend in 2023 and she never saw him or met him. She said the resident had a fall on admission [DATE]) and 2 days (11/26/23) later but she was not notified of the fall that occurred until 11/26/23 when the resident fell again and was sent out to the hospital. DON C said after CR #2's first fall on 11/24/23 nursing staff placed the resident's bed in a low position and placed fall mats around his bed. She said these interventions were put into place by LVN D but there was no documentation in the resident's record but she received this information from interviews with staff. DON C said placing a resident's bed in low position or the use of fall mats did not require an order so it would not be documented as an order but in a progress note to address interventions in place. She said normally the DON reviews the resident's chart after a fall investigating the fall and initiating any interventions/training but since CR #2 was transferred to the hospital on [DATE] she did not investigate his fall on 11/24/23. DON C said there was no other documentation outside of the resident's chart and looking back at the incident she identified discrepancies between the documentation and interviews in LVN D's timeline of the fall on 11/26/23. In an interview on 03/18/24 at 05:39 PM, CNA B said she didn't remember specific details about CR #2's fall. She said on 11/26/23 CR #2 fell and there was blood all over the wall, but she didn't know what assessments were performed on the resident after the fall or what interventions were in place prior. 676420 Page 16 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of LVN D's Official Training Transcript dated 02/29/24 revealed, no documented training on falls. The only training on her transcript was Monitoring Changes of Condition completed on 08/24/23. Record review of the facility policy titled Neurological Assessment revised 10/2019 revealed, 1- neurological assessments are indicated: b- following an unwitnessed fall; c- following a fall or other accident/injury involving head trauma. Record review of the facility policy titled Falls-Clinical Protocol revised 03/2018 revealed, Cause Identification- for an individual who has fallen the staff and practitioner will being to try to identify possible causes of the fall within 24 hours. Record review of the facility provided document titled Assessments Protocol for Patient Falls with no revision date revealed, 5- Neuro checks to be completed and charted as follows: every 15 minutes for 4 hours; every 30 minutes for 2 hours; every hour for 6 hours and every shift for 3 days. 676420 Page 17 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care and the facility failed to provide care which included but not limited to assessing, evaluating, planning and implementing resident care plans and responded to resident needs for 1 of 5 residents (Residents #2) and 1 of 3 nurses (RN D) reviewed for nurse competency. - The facility failed to ensure RN D was trained to admit residents and reconcile medications, prior to providing nursing services for Resident #2. This failure could place residents at risk of receiving inadequate care and harm. Findings included: Record review of Resident #2's Face Sheet dated 02/29/24 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: Parkinson's Disease, hypertension, restless syndrome, hallucinations and depression. Record review of Resident #2's Entry MDS dated [DATE] revealed, the resident admitted from a short-term general hospital. Record review of Resident #2's undated Care Plan revealed, focus- pain r/t restless leg syndrome and Parkinson's disease; intervention- administer pain meds as ordered. An observation and interview of Resident #2 on 02/27/24 at 12:45 PM revealed, Resident #2 sitting in his wheelchair in his room, in no immediate distress and with no observed tremors. The resident said he was doing well, and he had no issues with his medications or delay in care when he admitted to the facility. Resident #2 said everything is great. Record review of the facility provided Emergency Drug Kit Inventory filled 02/14/24 revealed, the kit contained: - Carbidopa/Levodopa 25-100 mg. Record review of Resident #2's Hospital Discharge Medication List dated 02/25/24 at 12:05 PM revealed: - Horizant 600 mg (medication used for nerve damage)- 1 tablet daily; next dose due at 6 PM. - Carbidopa-Levodopa 25-100 mg (medication used to treat Parkinson's disease)- 4 times daily. - Latanoprost 0.005% eye drops (medication used to treat glaucoma)- 1 drop every evening. - Pramipexole 0.5 mg (medication used to treat the symptoms of Parkinson's disease)- t ab by mouth - Ranolazine 500 mg (medication used to treat chronic chest pain)- 1 tablet 2 times a day 676420 Page 18 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Sucralfate 1g (medication used to treat stomach ulcers)- 1 tablet by mouth four times daily before meals and at bedtime. Record review of Resident #2's admission summary dated [DATE] at 02:30 PM signed by RN D revealed, history of Parkinson's disease, restless leg syndrome, and neuropathy. Resident #2's speech was minimal due to his progression of Parkinson's but his behavior was pleasant and cooperative. The facility staff and Resident #2's NP were notified of the residents admission. There was no documentation about medication availability, or communication with the pharmacy or resident's MD or NP about medication availability. Record review of Resident #2's Order Summary Report revealed: - Carbidopa-Levodopa Oral Tablet 25-100 MG- Give 1 tablet by mouth four times a day - Horizant Oral Tablet Extended Release 600 MG- (Gabapentin Enacarbil) Give 1 tablet by mouth at bedtime for restless legs - Latanoprost Ophthalmic Solution 0.005 %- (Latanoprost) Instill 1 drop in both eyes at bedtime for Glaucoma. Start date scheduled for 02/26/23. Ranolazine ER Oral Tablet Extended Release 12- Hour 500 MG (Ranolazine) Give 1 tablet by mouth two times a day. - Sucralfate Oral Tablet 1 GM (Sucralfate) Give 1 tablet by mouth four times a day for antacid Give before meals and at bedtime. Record review of Resident #2's February 2024 MAR revealed:, - Horizant 600 mg- 1 tablet by mouth scheduled for 08:00 PM not administered on 02/25/24. - Latanoprost 0.006% eye drops- 1 drop in both eyes; scheduled for 08:00 PM not administered on 02/25/24. - Ranolazine 500 mg ER, scheduled for 08:00 PM not administered on 02/25/24. - Ranolazine 500 mg ER, scheduled for 08:00 PM not administered on 02/26/24 at 08:00 AM. - Carbidopa-Levodopa 25-100 mg- not administered on scheduled doses on 02/25/24 at 08:00 PM and 02/26/25 at 08:00 AM - Sucralfate 1 gm- not administered on 02/25/24 at 08:00 PM, 02/26/24 at 07:00 AM and 02/26/24 at 11:30 AM. Record review of Resident #2's Progress Notes dated 02/27/24 at 12:56 PM revealed, Note: [Family 676420 Page 19 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Member] concerned with Carbidopa-Levodopa dosage, stated the dose was cut in half and client's Parkinson's symptoms were worsening. Providers notified and new order started. In an interview on 02/27/24 at 02:10 PM, DON B said she just took over the role a month ago and she was still in the process of reviewing/auditing trainings, in services and processes to ensure the facility was in compliance. In an interview on 02/29/24 at 08:49 AM, DON B said when a resident admits the admitting nurse and the admission nurse work together to receive the patient, check vitals and then enter admitting orders. She said medication orders should be entered and started based on the discharge medication med list and the next due dose. She said admission orders should be entered within an hour of admission and the pharmacy had specific cut off times but there was always the option for stat deliveries. DON B said if a resident arrived around 2:00 PM nurses are expected to retrieve their first doses from the e-kit and if the medication was not available they could follow up with the resident's family to see if they had any available or request a stat order from the pharmacy. DON B said if a nurse identifies a medication as unavailable they are expected to call the pharmacy to coordinate a stat deliver and if the medication was unavailable call the MD to ask for an alternative medication. She said nurses are expected to document the steps they took to resolve the medication discrepancy, who they talked to and the outcome in the resident's chart. DON B said failure to enter medication orders timely, or administer medications immediately upon admission could result in a delay in care, or missed doses that could place a resident at risk of a change of condition. DON B said training on admissions was done during a nurses onboarding. In an interview on 02/29/24 at 10:05 AM, RN D said she was Resident #2's admitting nurse. She said Resident #2's admission was the first one she completed on her own and she stayed over her shift to ensure she completed everything. RN D said Resident #2 admitted over the weekend so the facility admission nurse was unavailable to assist her during the admissions process. RN D said she started in the facility in December of 2023 and she never completed her training on admissions and physician notification in the facility because on her 3rd day of training she was placed on the floor but she had completed admissions at her previous job. She said she just missed that Resident #2 did not have medications available for immediate administration and if since the Resident #2 admitted at 02:30 PM she should have received his medications through a stat delivery or the e-kit and the error was on her. RN D said the time documented on the resident's admission note (02:30 PM) was the time she actually received the patient. RN D said when a resident admits nursing staff are expected to start the medications based on the discharge records and first doses can be retrieved from the facility e-kit but if medications were not in the kit she was expected to call the pharmacy to try and get a stat order, contact the doctor for an alternative if necessary and document any action taken if necessary. She said when she admitted Resident #2 she did not identify any missing doses, did not check the e-kit for any of the resident's first doses, did not contact the pharmacy to receive a stat delivery, did not contact the physician for alternative medications, did not notify the next nurse at change of shift of the unavailable medications, and did not document any medication issues in the resident's chart RN D said failure to administer medication timely on admission could result in adverse reactions, and in Resident #2's case upset stomach from not receiving his sucralfate or worsening of Parkinson's symptoms as a result of missing his Carbidopa-Levodopa. In an interview on 02/29/24 at 10:39 AM, DON B said the facility did not have a specific policy addressing physician notifications and nursing staff were expected to follow the admission Checklist but it was not expected to be included in the resident's chart, the document was just to be used as a reference. 676420 Page 20 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview and record review on 02/29/24 at 01:40 PM, the Chief Clinical Officer provided the surveyors with training records for RN D. The document presented was blank there were no recorded trainings, and the Chief Clinical Officer said the facility had no documented training for RN D. In an interview on 03/20/24 at 04:34 PM, DON B said the DON was responsible for ensuring that training for all nursing staff was completed and failure to complete training could place resident at risk for adverse events, incorrect documentation and incorrect assessments. In an interview on 03/20/24 at 04:34 PM, the Chief Clinical Officer said that prior the surveyors visit the facility did not have a formal auditing process for staff training and it was solely the responsibility of the DON but going forward the DON and HR director would be monitoring each staff member to ensure their training was completed before they hit the nursing floor. Record review of the facility provided blank admission Checklist revealed, nursing items to be completed: verify order from MD, verify order from pharmacy, contact pharmacy to confirm orders and delivery time. Record review of the facility policy titled Reconciliation of Medication on Admission revised 07/2017 revealed, General Guidelines. 1-medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route and indication for use for the purpose of preventing unintended changes or omissions at transition points of care. 2- Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during admission/transfer process. Steps in the procedure. 6- if there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: d- contact the resident's primary physician(s) in the community; e- contact the resident's secondary physician(s) in the community; f- contact the community pharmacy used by the resident; g- contact the admitting and/or attending physician. 7- document findings and actions. Documentation. 1- document was actions were taken by the nurse to resolve the discrepancy; 3- if the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, 4medications are administered in accordance with prescribers orders, including any required timeframe. 5Medication administration times are determined by resident need and benefit, not staff convenience. Factures that are considered include: a- enhancing optimal therapeutic effect of medication; b- preventing potential medication or food interactions' and honoring resident choices and preferences, consistent with his or her care plan. 676420 Page 21 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

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 2 of 5 residents (Resident #2 and Resident #3) reviewed for pharmacy services in that: - The facility failed to enter orders as well as acquire and administer medications to Resident #2 as ordered immediately upon admission. - The facility failed to retrieve Resident #2's initial dose of medication from the facility emergency kit. - The facility failed to acquire and administer medications to Resident #3 as ordered immediately upon admission. These failures could place residents at risk of not receiving medications as ordered by their physician, inadequate disease management, uncontrolled pain, seizures, and serious harm. The findings included: Resident #2 Record review of Resident #2's Face Sheet dated 02/29/24 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: Parkinson's Disease, hypertension, restless syndrome, hallucinations and depression. Record review of Resident #2's Entry MDS dated [DATE] revealed, the resident admitted from a short-term general hospital. Record review of Resident #2's undated Care Plan revealed, focus- pain r/t restless leg syndrome and Parkinson's disease; intervention- administer pain meds as ordered. An observation and interview of Resident #2 on 02/27/24 at 12:45 PM revealed, Resident #2 sitting in his wheelchair in his room, in no immediate distress and with no observed tremors. The resident said he was doing well and he had no issues with his medications or delay in care when he admitted to the facility. Resident #2 said everything is great. Record review of the facility provided Emergency Drug Kit Inventory filled 02/14/24 revealed, the kit contained: - Carbidopa/Levodopa 25-100 mg. Record review of Resident #2's Hospital Discharge Medication List dated 02/25/24 at 12:05 PM revealed: - Horizant 600 mg (medication used for nerve damage)- 1 tablet daily; next dose due at 6 PM. 676420 Page 22 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0755 - Carbidopa-Levodopa 25-100 mg (medication used to treat Parkinson's disease)- 4 times daily. Level of Harm - Minimal harm or potential for actual harm - Latanoprost 0.005% eye drops (medication used to treat glaucoma)- 1 drop every evening. - Pramipexole 0.5 mg (medication used to treat the symptoms of Parkinson's disease)- t ab by mouth Residents Affected - Some - Ranolazine 500 mg (medication used to treat chronic chest pain)- 1 tablet 2 times a day - Sucralfate 1g (medication used to treat stomach ulcers)- 1 tablet by mouth four times daily before meals and at bedtime. Record review of Resident #2's admission summary dated [DATE] at 02:30 PM signed by RN D revealed, history of Parkinson's disease, restless leg syndrome, and neuropathy. Resident #2's speech was minimal due to his progression of Parkinson's but his behavior was pleasant and cooperative. The facility staff and Resident #2's NP were notified of the residents admission. There was no documentation about medication availability, or communication with the pharmacy or resident's MD or NP about medication availability. Record review of Resident #2's Order Summary Report revealed, - Carbidopa-Levodopa Oral Tablet 25-100 MG- Give 1 tablet by mouth four times a day - Horizant Oral Tablet Extended Release 600 MG- (Gabapentin Enacarbil) Give 1 tablet by mouth at bedtime for restless legs - Latanoprost Ophthalmic Solution 0.005 %- (Latanoprost) Instill 1 drop in both eyes at bedtime for Glaucoma. Start date scheduled for 02/26/23. Ranolazine ER Oral Tablet Extended Release 12- Hour 500 MG (Ranolazine) Give 1 tablet by mouth two times a day. - Sucralfate Oral Tablet 1 GM (Sucralfate) Give 1 tablet by mouth four times a day for antacid Give before meals and at bedtime. Record review of Resident #2's February 2024 MAR revealed, - Horizant 600 mg- 1 tablet by mouth scheduled for 08:00 PM not administered on 02/25/24. - Latanoprost 0.006% eye drops- 1 drop in both eyes; scheduled for 08:00 PM not administered on 02/25/24. - Ranolazine 500 mg ER, scheduled for 08:00 PM not administered on 02/25/24. - Ranolazine 500 mg ER, scheduled for 08:00 PM not administered on 02/26/24 at 08:00 AM. 676420 Page 23 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0755 Level of Harm - Minimal harm or potential for actual harm - Carbidopa-Levodopa 25-100 mg- not administered on scheduled doses on 02/25/24 at 08:00 PM and 02/26/25 at 08:00 AM - Sucralfate 1 gm- not administered on 02/25/24 at 08:00 PM, 02/26/24 at 07:00 AM and 02/26/24 at 11:30 AM. Residents Affected - Some Record review of Resident #2's Progress Notes dated 02/27/24 at 12:56 PM revealed, Note: [Family Member] concerned with Carbidopa-Levodopa dosage, stated the dose was cut in half and client's Parkinson's symptoms were worsening. Providers notified and new order started. In an interview on 02/29/24 at 10:05 AM, RN D said she was Resident #2's admitting nurse. She said Resident #2's admission was the first one she completed on her own and she stayed over her shift to ensure she completed everything. RN D said Resident #2 admitted over the weekend so the facility admission nurse was unavailable to assist her during the admissions process. RN D said the time documented on the resident's admission note (02:30 PM) was the time she actually received the patient. RN D said when a resident admits nursing staff are expected to start the medications based on the discharge records and first doses can be retrieved from the facility e-kit but if medications were not in the kit she was expected to call the pharmacy to try and get a stat order, contact the doctor for an alternative if necessary and document any action taken if necessary. She said when she admitted Resident #2 she did not identify any missing doses, did not check the e-kit for any of the resident's first doses, did not contact the pharmacy to receive a stat delivery, did not contact the physician for alternative medications, did not notify the next nurse at change of shift of the unavailable medications, and did not document any medication issues in the resident's chart. RN D said she started in the facility in December of 2023 and she never completed her training on admissions and physician notification in the facility because on her 3rd day of training she was placed on the floor but she had completed admissions at her previous job. She said she just missed that Resident #2 did not have medications available for immediate administration and if since the Resident #2 admitted at 02:30 PM she should have received his medications through a stat delivery or the e-kit and the error was on her. RN D said failure to administer medication timely on admission could result in adverse reactions, and in Resident #2's case upset stomach from not receiving his sucralfate or worsening of Parkinson's symptoms as a result of missing his Carbidopa-Levodopa. Resident #3 Record review of Resident #3's Face Sheet dated 02/29/24 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of: type 2 diabetes, high blood pressure and irregular heartbeat. Record review of Resident #3's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15 and an active diagnoses of high blood pressure and irregular heartbeat. Record review of Resident #3's undated Care Plan revealed, focus- on anticoagulant (blood thinner) for unspecified irregular heart beat; intervention administer anticoagulant as ordered. Focus- resident has diabetes; intervention- administer diabetes medications as ordered by doctor. An observation and interview on 02/27/24 revealed, Resident #3 in her room, she appeared well groomed, well fed and in no immediate distress. She said when she arrived at the facility there was no delay in care and she promptly received her medications. She reported no symptoms of high or low blood 676420 Page 24 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0755 sugars. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's Hospital Discharge Medication List dated 02/22/24 at 09:09 AM revealed: Residents Affected - Some - Amiodarone 200 mg ( medication for irregular heartbeat) - 2 times daily at 09:00 AM and 5 PM; last dose at 02/22/24 at 09:03 AM - Atorvastatin 40 mg (medication for high cholesterol)- 1 time daily at bedtime; last dose on 02/21/24 at 09:49 PM. - Rivaroxaban 20 mg (a blood thinner)- 1 time daily with dinner; last dose on 02/21/24 at 05:19 PM. - Metformin XR 1000 mg- take 2 tablets twice a day with meals. Record review of Resident #3's Order Summary Report revealed, - Amiodarone HCl Oral Tablet 200 MG - Give 1 tablet by mouth every 12 hours for Irregular heart beat; start 02/22/24. - Atorvastatin Calcium Oral Tablet 40 MG- Give 1 tablet by mouth at bedtime for irregular heart beat; start 02/22/24. - Metformin Extended Release 24 Hour 1000 MG - Give 1 tablet by mouth two times a day with meals for type 2 diabetes. - Rivaroxaban 20 mg- 1 tablet by mouth in the evening for irregular heart beat; start 02/22/24. Record review of Resident #3's February MAR revealed: - Amiodarone 200 mg scheduled for 02/22/24 at 08:00 PM was not administered. - Atorvastatin 40 mg scheduled for 02/22/24 at 08:00 PM was not administered. - Metformin ER 1000 mg scheduled for 02/22/24 at 02:00 PM was not administered - Rivaroxaban 20 mg scheduled for 02/22/24 at 04:00 PM was not administered. Record review of the facility provided Emergency Drug Kit Inventory filled 02/14/24 revealed, the kit contained: - the emergency kit did not contain Resident #3's Amiodarone 200 mg, Atorvastatin 40 mg, Rivaroxaban 20 mg or Metformin XR 1000mg. Record review of Resident #3's Progress Note dated 02/22/24 at 02:07 PM by RN D revealed, a past medical history of irregular heartbeat, type 2 diabetes and hypertension. There was no documentation about medication availability, or communication with the pharmacy or resident's MD or NP about medication availability. 676420 Page 25 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0755 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's medication order Audit details revealed, the admitting nurse entered Resident #3's medications promptly upon admission at 02:08 PM (8 minutes after admission). Record review of Resident #3's Progress Notes for 02/22/24 to 02/23/24 revealed, no documentation explaining why Resident #3 did not receive her medications on 02/22/24. Residents Affected - Some Record review of Resident #3's Blood Sugars from 02/22/24 to 02/29/24 revealed, Resident #3's blood sugars ranged from 82 mg/dL to 145 mg/dL there was no documented hypo or hyperglycemia (low or high blood sugars). In an interview on 02/29/24 at 08:49 AM, DON B said when a resident admits the admitting nurse and the admission nurse work together to receive the patient, check vitals and then enter admitting orders. She said medication orders should be entered and started based on the discharge medication med list and the next due dose. She said admission orders should be entered within an hour of admission and the pharmacy had specific cut off times but there was always the option for stat deliveries. DON B said if a resident arrived around 2:00 PM nurses are expected to retrieve their first doses from the e-kit and if the medication was not available they could follow up with the resident's family to see if they had any available or request a stat order from the pharmacy. DON B said if a nurse identifies a medication as unavailable they are expected to call the pharmacy to coordinate a stat deliver and if the medication was unavailable call the MD to ask for an alternative medication. She said nurses are expected to document the steps they took to resolve the medication discrepancy, who they talked to and the outcome in the resident's chart. DON B said failure to enter medication orders timely, or administer medications immediately upon admission could result in a delay in care, or missed doses that could place a resident at risk of a change of condition. In an interview on 02/29/24 at 10:05 AM, RN D said she was Resident #3's admitting nurse. She said she was only responsible for assessing Resident #3 and the admissions nurse entered the residents medication orders. In an interview on 02/29/24 at 10:39 AM, DON B said the facility did not have a specific policy addressing physician notifications and nursing staff were expected to follow the admission Checklist but it was not expected to be included in the resident's chart, the document was just to be used as a reference. In an interview and record review on 02/29/24 at 01:40 PM, the Chief Clinical Officer provided the surveyors with training records for RN D. The documented presented was blank there were no recorded trainings and the Chief Clinical Officer said the facility had no documented training for RN D. Record review of the facility provided blank admission Checklist revealed, nursing items to be completed: verify order from MD, verify order from pharmacy, contact pharmacy to confirm orders and delivery time. Record review of the facility policy titled Reconciliation of Medication on Admission revised 07/2017 revealed, General Guidelines. 1-medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route and indication for use for the purpose of preventing unintended changes or omissions at transition points of care. 2- Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without 676420 Page 26 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interruption, in the correct dosages and routes, during admission/transfer process. Steps in the procedure. 6- if there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: d- contact the resident's primary physician(s) in the community; e- contact the resident's secondary physician(s) in the community; f- contact the community pharmacy used by the resident; g- contact the admitting and/or attending physician. 7- document findings and actions. Documentation. 1- document was actions were taken by the nurse to resolve the discrepancy; 3- if the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift. Record review of the facility policy titled Administering Medications revised 04/2019 revealed, 4medications are administered in accordance with prescribers orders, including any required timeframe. 5Medication administration times are determined by resident need and benefit, not staff convenience. Factures that are considered include: a- enhancing optimal therapeutic effect of medication; b- preventing potential medication or food interactions' and honoring resident choices and preferences, consistent with his or her care plan. 676420 Page 27 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (CR #2) whose records were reviewed for resident identifiable records. - The facility failed to completely and accurately document interventions, assessments and neurological checks performed on CR #2 following falls on 11/24/23 and 11/26/23. This failure could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings included: Record review of CR #2's Face Sheet dated 02/29/24 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: hypertension and muscle wasting. The resident was transferred to the hospital on [DATE]. Record review of CR #2's undated Care Plan revealed, focus- risk for falls r/t muscle wasting, history of falls; intervention- if fall occurs initiate frequent neuro and bleeding evaluation per facility policy. Record review of CR #2's EMR revealed, the MDS was yet to be completed because the resident was a new admission. Record review of CR #2's Clinical Assessments revealed: - CR #2's neuros were only documented twice on 11/24/23 at 08:15 Pm and 08:30 PM. No neuros were performed on 11/25/23 or 11/26/23. Record review of CR #2's EMR revealed, no additional paper neurological checks uploaded except for dose found under the clinical assessments. Record review of CR #2's Progress Notes dated 11/24/23 at 08:00 PM signed by LVN D revealed, CR #2 had an unwitnessed fall in his room. The cause of the fall was not evident, and the resident hit his head, but the fall did not result in an ER visit. CR #2's MD was notified, and no new orders were received. Record review of CR #2's Neurological Checklist dated 11/24/23 at 08:15 PM signed by LVN D revealed, CR #2 was not oriented to time, was confused, had normal pupil responses and ROM and a pain score of 06 out of 10. Record review of CR #2's Neurological Checklist dated 11/24/23 at 08:30 PM signed by LVN D revealed, CR #2 was not oriented to time, had normal pupil responses and ROM and a pain score of 04 out of 10. CR #2 had not complaints of any pain, dizziness, nausea or vomiting. Record review of CR #2's Clinical Assessments revealed, no neurological checks documented after 676420 Page 28 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0842 11/24/23 at 08:30 PM. Level of Harm - Minimal harm or potential for actual harm Record review of CR #2's Progress Notes from 11/24/23 to 11/26/23 revealed, no documented interventions between CR #2's two falls. Residents Affected - Few Record review of CR #2's Provider Note dated 11/26/23 at 01:40 PM, Per nurse, the patient had fall on 1st day of admit [11/24/23]. The resident was A&O X 3 and able to move all extremities. Record review of CR #2's Progress Notes dated 11/26/23 at 08:00 PM signed by LVN D revealed, CR #2 had an unwitnessed fall in his bathroom., He was found of the floor of the bathroom with blood coming out of his head. Record review of CR #2's Activity Participation Note dated 11/26/23 signed by LVN D revealed: - 08:00 PM CR #2 was found on the floor of the bathroom shower. There was blood all over the bathroom with further investigation there was a laceration approximal 1.5 inches in the back of his head. - 08:15 PM Patient was assisted off floor of the bathroom to his wheelchair for further assessment. Wound was cleaned and measured for size and damage. Neuro checks were performed and vital signs were taken all WNL. - 09:00 PM 911 was called, NP had a message left for her since there was no answer. CR #2's family member was called and informed of the incident and which hospital we were sending the patient. She advised that she would meet him at the ER. Record review of CR #2's Hospital EMS record dated 11/26/23 revealed: the facility called in the incident on 11/26/23 at 08:43 PM, the ambulance was notified, dispatched and enroute at 08:45 PM, the ambulance arrived on the scene at 08:47 PM, arrived at CR #2 at 08:54 PM, departed the facility with CR #2 at 09:00 PM and arrived at the hospital at 09:12 PM. The EMS staff arrived to the facility and found CR #2 sitting in a wheelchair by the nursing station waiting for transport to the hospital and CR #2 said he lost his footing while going to the bathroom and fell to the ground where he struck the back of his head. CR #2 had a 1 inch long laceration to the back of his head and his bleeding was controlled by CR #2 with a towel. In an interview on 02/29/24 at 08:49 AM, DON B said when a resident has an unwitnessed fall nursing staff are expected to assess the resident for injuries, changes in ROM and pain from baseline as well as performing neurological checks and details should be documented in the residents chart completely. She said after reviewing CR #2's file they identified that nursing staff failed to complete neuro checks on the resident following the fall on 11/24/23 and 11/26/23. There was no documentation that neuro checks were performed on CR #2 correctly on 11/24/23 not just the 2 15 minute checks the resident would have still been receiving neurological checks on 11/26/23 when he suffered the second fall. DON B said the purpose of performing neuro checks after unwitnessed falls or head injuries is to identify any potential brain injuries/bleeds. DON B said she did not know what particular corrective interventions was completed regarding CR #2's fall because DON A was the DON at the time of the fall and interventions were not documented in the chart. DON B said failure to document completely and accurately could result in inaccurate records and an inaccurate representation of the patient. 676420 Page 29 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 03/15/24 at 01:27 PM, LVN D said on 11/24/23 CR #2 apparently slid out of his wheelchair trying to get into the chair. She said the resident was assessed and was found to have no bruising, injuries, skin intact and no evidence of injury. LVN D said the resident was not hurt and did not hit his head per his statement but she initiated neuro checks and notified the MD. She said the MD (not specified) said neuro checks only had to be done every 4 hours since the resident was not injured and was able to verbalize that he did not hit his head. LVN D said after the first fall staff ensured that CR #2's bed was in the lowest position and fall mats were placed by his bed. She said the resident did not like the feeling of the mats on his feet so it kept him from getting out of bed unassisted. LVN D said the facility staff checked on him frequently but she did not document that he was being monitored. She said on 11/26/23 she saw the resident at 07:30 PM sitting in his wheelchair watching television in his room and at approximately 08:00 PM the resident was found on the floor in the bathroom. LVN D said she assessed the resident , started neuro checks at 08:15 PM and the EMS arrived at approximately 08:30 PM. She said once the EMS arrived she handed off the resident and the EMS were on sight for 20-25 minutes prior to leaving for the hospital. LVN D she might have not documented all CR #2's neuro checks but they were done and she was working to improve her documentation. LVN D said she should have done a better job on her documentation. In an interview on 03/18/24 at 01:04 PM, DON C said she was the interim DON between DON A and DON B when CR #2 had his fall in 11/2023. She said all new residents received a fall assessment and all new admissions are considered a high fall risk due to the change in environment. DON C said residents who are considered to be at high risk for falls have their call light as well as all necessities placed within reach and nursing staff round on them every 2 hours. She said rounding every 2 hours was a standard protocol upon admission and it did not require an order documented the EMR. DON C said after a resident falls nursing staff are expected to assess the resident for injuries, check vitals, complete a post fall risk evaluation and then notify the family, the resident's physician and nursing administration. She said if the resident's fall was unwitnessed then neuro checks must be performed following the facility protocol at set intervals for 72 hours, these checks should be documented in the EMR or on paper and the information about the fall should be communicated during shift change and entered into the 24 hour report DON C said CR #2 admitted into the facility on Thanksgiving weekend in 2023 and she never saw him or met him. She said the resident had a fall on admission [DATE]) and 2 days (11/26/23) later but she was not notified of the fall that occurred until 11/26/23 when the resident fell again and was sent out to the hospital. DON C said after CR #2's first fall on 11/24/23 nursing staff placed the resident's bed in a low position and placed fall mats around his bed. She said these interventions were put into place by LVN D but there was no documentation in the resident's record but she received this information from interviews with staff. DON C said placing a resident's bed in low position or the use of fall mats did not require an order so it would not be documented as an order but in a progress note to address interventions in place. DON C said after the resident transferred to the hospital on [DATE] she did not look into the fall from 11/24/23 or investigate it further because the resident was in the hospital. DON C said there was no other documentation outside of the resident's chart and looking back at the incident she identified discrepancies between the documentation and interviews in LVN D's timeline of the fall on 11/26/23. Record review of the facility policy titled Charting and Documentation revised 07/2017 revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's 676420 Page 30 of 31 676420 03/20/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition and response to care. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. Record review of the facility policy titled Falls-Clinical Protocol revised 03/2018 revealed, Cause Identification- for an individual who has fallen the staff and practitioner will being to try to identify possible causes of the fall within 24 hours. 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. Change in cognition or level of consciousness; e. Neurological status; f. Pain; g. Frequency and number of falls since last physician visit; h. Precipitating factors, details on how fall occurred; i. All current medications, especially those associated with dizziness or lethargy; and j. All active diagnoses. 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Record review of the facility provided document titled Assessments Protocol for Patient Falls with no revision date revealed, 5- Neuro checks to be completed and charted as follows: every 15 minutes for 4 hours; every 30 minutes for 2 hours; every hour for 6 hours and every shift for 3 days. Record review of the facility policy titled Neurological Assessment revised 10/2019 revealed, 1- neurological assessments are indicated: b- following an unwitnessed fall; c- following a fall or other accident/injury involving head trauma. Documentation- The following information should be recorded in the resident's medical record: 1- The date and time the procedure was performed; 2- The name and title of the individual(s) who performed the procedure; 3- All assessment data obtained during the procedure; 4- How the resident tolerated the procedure; 5- If the resident refused the procedure, the reason(s) why and the intervention taken; 6- The signature and title of the person recording the data. Record review of the facility policy titled Change in a Resident's Conditions or Status revised 02/2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 676420 Page 31 of 31