Health inspection·June 15, 2023

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs for one (Resident #49) of three residents reviewed for PASRR assessments. Residents Affected - Few The facility failed to recognize Resident #49 had diagnosis of anxiety disorder, major depressive disorder, and bipolar disorder on admission and as a result she never received a PASRR Level II assessment Evaluation. This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs. Findings included: Review of Resident #49's admission MDS dated [DATE] revealed, a [AGE] year-old female who admitted to the facility 04/19/23 with the diagnoses to include: bipolar disorder, major depressive disorder, and anxiety disorder. The resident had a BIMS score of 14, indicating her cognition was intact, and required assist of one staff for ADLs. Review of Resident #49's Physician's Orders Summary Report dated June 2023June 2023 revealed, Bipolar disorder, Cymbalta( antidepressantCymbalta(antidepressant) and Lamotrigene Lamotrigine(Lamictal) (anticonvulsant): Monitor and document any side effects related to use of antipsychotic medication. included: Cymbalta oral capsule delayed release particles 60mg give 1 capsule by mouth two times a day related to bipolar disorder. Lamotrigine oral tablet 200mg give 1 tablet by every morning and at bedtime related to bipolar disorder. Major Depressive disorder, Amitriptyline ( antidepressant(antidepressant): Monitor and document any side effects related to the usage of antidepressant drugs. Amitriptyline HCL oral tablet 25mg give 1 tablet by mouth at bedtime related to major depressive disorder. Page 1 of 5 676474 676474 06/15/2023 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0645 Review of Resident #49's MAR dated May and June 2023, revealed the following orders: Level of Harm - Minimal harm or potential for actual harm Order date 04/19/23: Cymbalta oral capsules delayed release particles 60mg give 1 capsule by mouth two times a day for bipolar disorder. Residents Affected - Few Further review of the MAR revealed Resident #49 had received her Cymbalta for the month of May and June 2023. Review of Resident #49's MAR dated May and June 2023, revealed the following orders: Order date 04/19/23: Amitriptyline HCL oral tablet 25mg give 1 tablet by mouth at bedtime related to major depressive disorder. Further review of the MAR revealed Resident #49 had received her Lamotrigine for the month of May and June 2023. Review of Resident #49's MAR dated May and June 2023, revealed the following orders: Order date 04/19/23: Lamotrigine oral tablet 200mg give 1 tablet by every morning and at bedtime related to bipolar disorder. Further review of the MAR revealed Resident #49 had received her Lamotrigine for the month of May and June 2023. Review of Resident #49's PASRR Level 1 screen dated 04/19/23 revealed, Submitter information was the transferring facility, Referring Entity: .Nursing facility .C. 100. Mental Illness: No . This was her only PASRR Level 1 Screen found in the SIMPLE LTC system. In an interview on 6/14/23 at 4:00 p.m. with the MDS coordinator revealed she was responsible for the PASRR level 1 information when, the resident admits .are admitted The MDS coordinator stated when a resident admits to the facility, she reviews the resident's information that had been documented on the admission information on the PASRR level 1 and makes changes to the form, if required. She stated if the resident had a diagnosis of Mental Illness Health would answer yes to the question asking if they had a diagnosis, the LA would come to complete a PASRR level 2 to see if the resident qualifies for services. The MDS coordinator gave examples of diagnosis that she would check yes for: Schizophrenia, bipolar disorder, psychosis, anxiety with psychosis. She stated she had missed Resident 49's diagnoses of bipolar disorder and major depressive disorder; she would be completing a new PASRR 1 today. She stated that the follow-up for the PASRR 1 was her responsibly and the Social Worker's responsibilities was the meetings. If the resident qualified for services (specialized services) it would be the responsibility of that department manager to receive the orders and initiate the services. The MDS coordinator stated that there was no follow-up with the specialized services, except the scheduled meetings. The MDS coordinator stated that if the PASRR 1 assessment was not completed correctly the resident could not receive available services. The MDS coordinator stated when she reviewed the PASRR 1 that she had not reviewed the admitting diagnose appropriately, as the admission coordinator had competed the form, and she had missed the diagnosis of the mental illness. By missing the diagnosis at admission placed Resident #49 at risk of not receiving additional services. In an interview on 06/14/23 at 4:17 p.m. with the Administrator revealed nursingrevealed nursing services, the MDS coordinator, was responsible for reviewing the information and completing the PASRR 1. The Administrator said he did not have direct involvement with the PASRR process, if the residents had qualified for specialized services, he would be made aware of that by the Social Worker or the department head, and he would assist to assure that the services were provided. 676474 Page 2 of 5 676474 06/15/2023 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 06/15/23 at 9:45 a.m. with the DON revealed the facility would receive PASRR 1 already completed from the hospital, home, or another nursing facility. The PASRR 1 was reviewed by the MDS coordinator and if the residents required a PASRR level 2, those would be completed by the PASRR evaluator (LA), if services are needed then the facility proceeds with the services. The Social Worker is was responsibresponsibleility f or organizing and conducting the IDT meetings. The DON stated if the assessment (PASSR 1) was not completed properly, missing a diagnosis, then the PASRR level 2 would not be completed, and the resident could miss receiving services. In an interview on 06/15/23 at 11:00 a.m. with Resident #49 revealed she did not know anything about PASRR or specialized services, no one had talked to her about that. The resident said if she was entitled to something, she wanted to able to get it. Review of the facility's policy and procedure PASRR Nursing Facility Specialized Services Policy and Procedure undated reflected, Policy: It is the policy of the . facilities to ensure NFSS Forms are submitted timely and accurately Procedure PL1 is completed . if PL1 is coded as suspicion of MI (Mental Illness), ID ( Intellectual Disability) or DD ( disability Disorder) than a PE is required . the LA completes the PE and if Positive, an initial meeting is scheduled 676474 Page 3 of 5 676474 06/15/2023 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 5 of 30 days reviewed for RN coverage. Residents Affected - Some The facility failed to ensure they had an RN on duty on for 5 days: 09/03/22; 09/04/22; 09/12/22; 09/18/22 and 09/24/22. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of RN staffing hours for March 2023 reflected zero hours worked by an RN on 09/03/22 (Saturday); 09/04/22 (Sunday); 09/12/22 (Monday); 09/18/22 (Sunday), and 09/24/22 (Saturday). During an interview on 06/14/23 at 1:05 PM, the DON stated that she lived close to the facility and that she had covered many weekend hours for the facility. She stated that there may have been some occasions that RNs who worked double shifts on the weekends may have triggered the infraction dates on the PBJ report because they had to clock out for an hour for lunch. She further stated that there may have been a few days in September of 2022 that they might have LVNs on instead of RNs because there was a period that it had been very difficult to find PRN (Pro Re Nata, as necessary) RNs, but that she was sure that there had been very little time without an RN in the facility on those dates. The DON stated there was not an RN on duty on those indicated Saturdays or other Sundays in September 2023, and she understood it was an issue because of supervision. When asked to elaborate on possible negative outcomes to residents if no RN was on duty, she stated she did not think there would be one since she was on call and available all the time and could be at the building so quickly, but that it could possibly lead to missing assessments care or treatments. During an interview on 06/15/23 at 9:31 AM, ADM provided facility policy on departmental supervision and stated the policy required an LVN or RN to be always on duty. He acknowledged the facility policy did not meet the regulatory requirement. He stated that the facility always did have at least one RN on 24 hours a day, 7 days a week but that the reporting does not consider that the nurses pulling double shifts have an hour lunch break, and that may be the reason that it looks like they were missing RNs for those days reflected on the PBJ report. He stated that there may have been an LVN on as opposed to an actual RN, but that he always makes sure that the facility has some type of nurse coverage 24 hours a day. Record review of facility policy dated August 2006 reflected the following, Policy Statement: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. Policy Interpretation and Implementation: 1. A registered or licensed practical/vocational nurse (RN/LPN/LVN) is on duty 24 hours per day, seven days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 676474 Page 4 of 5 676474 06/15/2023 Le Reve Rehabilitation & Memory Care 3309 Dilido Road Dallas, TX 75228

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. A registered nurse (RN) is employed as the Director of Nursing Services. The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities, including the supervision of direct care staff. 3. The nurse supervisor/charge nurses are registered nurses (RN) or licensed practical vocational nurses (LPN/LVN) and are duly licensed by the state. 4. The Director of Nursing Services and/or the nurse supervisor/charge nurse, as a minimum, is responsible for: a. making daily resident visits to observe and evaluate the residence, physical and emotional status; b. reviewing medication, cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies; c. reviewing individual, resident care, plans for appropriate goals, problems, approaches, and revisions, based on nursing needs; d. Assuring that the residence plan of care is being followed; e. arranging schedule to allow time for supervision and evaluation of performance of nursing personnel, and paid feeding assistants; f. informing attending physicians and resident families of changes in the residence, medical condition; g. charting and documenting medical records as necessary; h. keeping Nursing Service Personnel, informed of status of residence, and other related matters through written reports and verbal communication; i. Assigning work schedules and staffing to meet the needs of residence; providing direct resident care as necessary or appropriate; j. and other tasks and functions, that may become necessary. 676474 Page 5 of 5