Health inspection·May 10, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 9 residents (Residents #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9) of 12 residents reviewed for medication administration were free of significant medication errors. Residents Affected - Some Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9 did not receive their evening medications scheduled in the evening (to be administered between 4:00pm and 6pm) on 05/01/24 and 05/07/24 as ordered by the physician, placing them at risk. These failures could place residents at risk for not receiving the intended therapeutic benefit of the medications. Findings included: Resident #1 Record review of the face sheet of Resident #1 dated 05/10/24 revealed Resident #1 was [AGE] years old and was initially admitted on [DATE] and re admitted to the facility on [DATE]. Her diagnoses included Hypertension, Unsteadiness on feet, Lack of Coordination, Asthma, Major Depressive Disorder, Alcoholic Cirrhosis of liver (Healthy liver cells are replaced by scar tissues), Type 2 diabetes Mellitus and Pain in left thigh, ankle, joints of left foot, lower leg, foot, and foot drop. Record review of the initial MDS of Resident #1 dated 02/25/24 revealed she had a BIMS score of 12, indicative of moderate cognitive impairment. Record review of the Care Plan of Resident #1 dated 03/05/24 revealed she had Hypertension and takes Gabapentin for Neuropathy. The relevant intervention was administering anti-hypertensive medications and Gabapentin as ordered by MD. Record review of the physician's order and the May 2024 MAR of Resident #1 revealed, there were physician's orders and on 05/01/24 and 05/07/24, Resident #1 did not receive the following medications scheduled in the evening (to be administered between 4:00pm and 6pm). 1. Propranolol HCl Oral Tablet 10 MG (Propranolol HCl): Give 1 tablet by mouth two times a day related to essential (primary) hypertension hold for sbp <110 or hr <60. Page 1 of 10 676475 676475 05/10/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0760 2. Gabapentin Oral Capsule 100 MG(Gabapentin): Level of Harm - Minimal harm or potential for actual harm Give 1 capsule by mouth three times a day related to alcoholic polyneuropathy. 3. Hydralazine hcl Oral Tablet 25MG (Hydralazine HCl): Residents Affected - Some Give 1 tablet by mouth three times a day related to essential (primary) hypertension. Hold if bp 100/60 hr 60. During an observation and interview on 05/10/24 at 3:00 p.m., Resident #1 was in her room sitting on a chair and stated she was not remembering omission of any medications. She stated she received all her medication on this day and on the previous day. Resident #2 Record review of the face sheet of Resident #2 dated 05/10/24 revealed Resident #2 was [AGE] years old and was initially admitted on [DATE] and re admitted to the facility on [DATE]. His diagnoses included Cerebral Infarction, Type 2 Diabetes Mellitus, Vascular Dementia (Memory Loss), Psychotic Disturbance, Mood Disturbance, and anxiety, Hypertension and Cognitive Communication Deficit (difficulty with thinking and how someone uses language.). Record review of the quarterly MDS dated [DATE] for Resident #2 revealed he had a BIMS score of 04, indicative of severe cognitive impairment. Record review of the Care Plan dated 03/08/24 for Resident #2 revealed he had Diabetes Mellitus and impaired thought processes related to Dementia. The relevant intervention was administering medications as ordered by MD. Record review of the physician's order and the May 2024 MAR of Resident #2 revealed, there were physician's orders and on 05/01/24, Resident #2 did not receive the following medications scheduled in the evening (to be administered between 4:00pm and 6pm). 1.Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium): Give 3 capsule by mouth two times a day related to dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. 2.metformin HCl Tablet 1000 MG: Give 1 tablet orally two times a day for hyperglycemia. Observation and interview on 05/10/24 at 11:00 a.m., revealed Resident #2 was laying in his bed and appeared confused. When the investigator asked if he received all his medications regularly, he nodded and said nothing. Resident #3 Record review of the face sheet of Resident #3 dated 05/10/24 revealed Resident #3 was [AGE] years old and was initially admitted on [DATE] and re admitted to the facility on [DATE]. Her diagnoses 676475 Page 2 of 10 676475 05/10/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0760 Level of Harm - Minimal harm or potential for actual harm included Cerebral Infarction, Muscle Spasm, Insomnia, Schizoaffective Disorder, Major Depressive Disorder, Hypertension, Cognitive Communication deficit, Pain, and Type 2 Diabetes Mellitus. Record review of the quarterly MDS of Resident #3 dated 04/02/24 revealed she had a BIMS score of 15, indicative of intact cognition. Residents Affected - Some Record review of the Care Plan dated 03/05/24 for Resident #3 revealed she had pain medication therapy related to CVA (stroke), muscle spasms. The relevant intervention was administering medication as ordered by MD. Record review of the physician's order and the May 2024 MAR of Resident #3 revealed, there were physician's orders and on 05/03/24 and 05/07/24, Resident #3 did not receive the following medication scheduled in the evening (to be administered between 4:00pm and 6pm). 1.Gabapentin Oral Tablet (Gabapentin): Give 600 mg by mouth three times a day related to pain, unspecified. Observation and interview on 05/10/24 at 11:30 a.m., revealed Resident #3 was lying in her bed and she stated she could remember about 05/03/24 and 05/07/24 . She stated she had all her medications this day and the previous day. She said her pain was under control with the help of her medications. Resident #4 Record review of the face sheet of Resident #4 dated 05/10/24 revealed Resident #4 was [AGE] years old and was admitted to the facility on [DATE]. Her diagnoses included Heart Failure, Major Depressive Disorder, Anxiety Disorder, Ischemic Cardiomyopathy (Heart's decreased ability to pump blood properly, due to myocardial damage brought upon by restricted oxygen supply), End stage Renal Disease (end stage Kidney disease), Generalized Anxiety Disorder, Chronic Pain, Type 2 Diabetes Mellitus, Fibromyalgia ( chronic fatigue and whole body pain) and Hypertension, Record review of the quarterly MDS dated [DATE] for Resident #4 revealed she had a BIMS score of 09, indicative of moderate cognitive impairment. Record review of the Care Plan dated 04/27/24 for Resident #4 revealed she had Congestive Heart Failure and was on Gabapentin for Chronic Pain Neuropathy. The relevant intervention was, administering cardiac and pain medications as ordered and requested. Record review of the physician's order and the May 2024 MAR of Resident #4 revealed, there were physician's orders and on 05/01/24 and 05/07/24, Resident #4 did not receive the following medications scheduled in the evening (to be administered between 4:00pm and 6pm). 1.Isosorbide Dinitrate Tablet 10 MG: Give 1 tablet by mouth two times a day for Heart failure related to acute systolic (congestive) heart failure 2. Gabapentin Capsule 300 MG: 676475 Page 3 of 10 676475 05/10/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0760 Give 1 capsule by mouth three times a day related to Fibromyalgia. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 05/10/24 at 3:00 p.m., revealed Resident #4 was sitting on her bed and communicating with her roommate. She stated she received medications regularly every day. Residents Affected - Some Resident #5 Record review of the face sheet Resident #5 dated 05/10/24 revealed Resident #5 was [AGE] years old and was initially admitted on [DATE] and re admitted to the facility on [DATE]. Her diagnoses included Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Major Depressive Disorder, Hypertension and Peripheral Autonomic Neuropathy (disorders affecting the peripheral nerves that automatically). Record review of the quarterly MDS dated [DATE] for Resident #5 revealed she had a BIMS score of 07, indicative of severe cognitive impairment. Record review of the Care Plan dated 02/15/24 for Resident #5 revealed she had Hypertension, GERD (stomach acid repeatedly flows back), neuropathy. The relevant intervention was administering relevant medications as ordered by the MD. Record review of the physician's order and the May 2024 MAR Resident #5 revealed, there were physician's orders and on 05/01/24 and 05/07/24, Resident #5 did not receive the following medications scheduled in the evening (to be administered between 4:00pm and 6pm). 1. Lisinopril Oral Tablet 20 MG(Lisinopril): Give 1 tablet by mouth two times a day for Essential (Primary) hypertension. 2. Neurontin Oral Capsule 300 MG(Gabapentin): Give 300 mg by mouth three times a day for neuropathy Take 300 mg BID and at night. Observation and interview on 05/10/24 at 1:00 p.m., revealed Resident #5 was in her bed awake however was unable to communicate. Resident #6 Record review of the face sheet of Resident #6 dated 05/10/24 revealed Resident #6 was [AGE] years old and was initially admitted on [DATE] and re admitted to the facility on [DATE]. Her diagnoses included Acute and Chronic Respiratory Failure, Constipation, Congestive Heart failure, Pain, and Anxiety Disorder, Record review of the quarterly MDS dated [DATE] for Resident #6 revealed she had a BIMS score of 12, indicative of moderate cognitive impairment. Record review of the Care Plan date 02/15/24 for Resident #6 revealed she had Hyperlipidemia and Constipation. She also had Pain medication Therapy of Tramadol related to Gout, Chronic Pain, and Peripheral Venous Insufficiency (Leg veins don't allow blood to flow back up to your heart) 676475 Page 4 of 10 676475 05/10/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0760 and constipation. The relevant intervention was, administering respective medications as ordered by MD. Level of Harm - Minimal harm or potential for actual harm Record review of the physician's order and the May 2024 MAR of Resident #6 revealed, there were physician's orders and on 05/01/24 and 05/07/24, Resident #6 did not receive the following medications scheduled in the evening (to be administered between 4:00pm and 6pm). Resident #6 received all her medications between 05/01/24 and 05/10/24, except these days. Residents Affected - Some 1) Baclofen Oral Tablet 5 MG(Baclofen): Give 1 tablet by mouth two times a day for muscle spasms of left leg. 2) MiraLax Oral Powder 17 GM/SCOOP (Polyethylene Glycol): Give 1 scoop by mouth two times a day for constipation. 3) Tramadol HCl Oral Tablet 50 MG (Tramadol HCl): Give 2 tablet by mouth every 8 hours related to pain, unspecified. 4) Bumex Oral Tablet 1 MG(Bumetanide): Give 3 tablet by mouth three times a day for fluid overload related to Heart Failure, unspecified. This medication was on hold starting from 5/7/24. 5) Gabapentin Oral Capsule 300 MG(Gabapentin): Give 1 capsule by mouth three times a day for Pain. Resident #6 did not receive this medication on 05/04/24 and 05/07/24 in the evening. During an observation and interview on 05/10/24 at 11:00 a.m., Resident #6 was laying in her bed alerted and oriented. She stated she did not receive her evening medications including pain medications on 05/08/24 and 05/09/24. She stated she was in pain on those days as she did not receive her pain medication Tramadol in the evening. When investigator asked about 05/01/24, 05/04/07 and 05/07/24, she reported she received all her medications on those days, and she was not suffering from pain on those days. Resident #7 Record review of the face sheet of Resident #7 dated 05/10/24 revealed Resident #7 was [AGE] years old and was initially admitted on [DATE] and re admitted to the facility on [DATE]. His diagnoses included Hemiplegia (complete paralysis) and Hemiparesis (partial weakness.), Hypertension, Type 2 Diabetes Mellitus, Symptomatic Epilepsy (seizure due to unknown cause) and Epileptic Syndromes and Major Depressive Disorder. 676475 Page 5 of 10 676475 05/10/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0760 Record review of the quarterly MDS dated [DATE] for Resident #7 revealed that his BIMS did not complete. Level of Harm - Minimal harm or potential for actual harm Record review of the Care Plan dated 03/09/24 for Resident #7 revealed he had following issues: 1.At risk for Hyperglycemic episodes and Hypoglycemic episodes due to diagnosis of Diabetes Mellitus Residents Affected - Some 2. Was potential for altered cardiac function. 3. He was undergoing diuretic therapy Lasix related to Edema and Hypertension. 4. Resident #7 had altered visual function related to Ocular Hypertension 5. At risk for injury related to Seizure Disorder 6. Resident #7 was potential for acute pain related to generalized aches and pains, Diabetic neuropathy, and chronic low back pain The relevant intervention was administering Diabetes medication Metformin, Anti-seizer and Antihypertensive medications and eye drops as ordered by the MD. Record review of physician's order and the May 2024 MAR of Resident #7 revealed, there were physician's orders on 05/01/24, Resident #7 did not receive the following medications scheduled in the evening (to be administered between 4:00pm and 6pm). 1) Lasix Oral Tablet 40 MG(Furosemide): Give 1 tablet by mouth two times a day for Hypertension. 2) Keppra Solution 100 MG/ML (Levetiracetam): Give 5 ml by mouth two times a day for seizures. 3) Metformin HCl ER Tablet Extended Release 24 Hour 500MG: Give 1 tablet by mouth two times a day related to type 2 Diabetes Mellitus with Hyperglycemia 4) Gabapentin Capsule 300 MG: Give 1 capsule by mouth three times a day for Neuropathy. 5) Refresh Optive Solution 0.5-0.9 % (Carboxymethylcellul-Glycerin): Instill 2 drop in both eyes two times a day related to low-tension glaucoma, bilateral, indeterminate stage. Observation and interview on 5/10/24 at 4:05 p.m., revealed Resident #7 was in his bed awake. He was unable to communicate appropriately. 676475 Page 6 of 10 676475 05/10/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0760 Resident #8 Level of Harm - Minimal harm or potential for actual harm Record review of the face sheet dated 05/10/24 revealed Resident #8 was [AGE] years old and was initially admitted on [DATE] and re admitted to the facility on [DATE]. Her diagnoses included Hypertension, Heart Failure, Atrial Fibrillation, Chronic Kidney disease, stage 3, and dementia. Residents Affected - Some Record review of the quarterly MDS dated [DATE] for Resident #8 revealed he had a BIMS score of 09, indicative of moderate cognitive impairment. Record review of the Care Plan date 04/24/24 for Resident #8 revealed he had heart failure. The relevant intervention was administering medications as ordered by MD. Record review of the physician's order and the May 2024 MAR of Resident #8 revealed, there were physician's orders on 05/01/24 and 05/07/24, Resident #8 did not receive the following medications scheduled in the evening (to be administered between 4:00pm and 6pm). 1) Amiodarone HCl Tablet 100 MG: Give 1 tablet by mouth in the evening related to paroxysmal. atrial fibrillations hold for sbp <100 dbp <60 or pulse <60 2) Apixaban Oral Tablet 5 MG (Apixaban): Give 5 mg by mouth two times a day for irregular heart rate. 3) Bumex Oral Tablet 2 MG (Bumetanide): Give 1 tablet by mouth two times a day for diuretic. Observation and interview on 05/10/24 at 10:45 a.m., revealed Resident #8 was in his wheelchair. He was responding by saying 'yes' or 'no'. When investigator asked if he had any issue with receiving his medications regularly, her stated no. Resident #9 Record review of the face sheet dated 05/10/24 revealed Resident #9 was [AGE] years old and was initially admitted on [DATE] and re admitted to the facility on [DATE]. His diagnoses included Cerebral Infarction (stroke) , Hypertension, Hemiplegia (complete paralysis )and Hemiparesis ( partial weakness.), and Hyperlipidemia (excess fat in blood). Record review of the quarterly MDS dated [DATE] for Resident #9 revealed he had a BIMS score of 09, indicative of moderate cognitive impairment. Record review of the Care Plan dated 02/13/24 for Resident #9 revealed he was on anticoagulant therapy. The relevant intervention was administering medication as ordered and monitor for side effects. Record review of the physician's order and the May 2024 MAR of Resident #7 revealed, there were physician's orders and on 05/01/24, Resident #9 did not receive the following medications scheduled in 676475 Page 7 of 10 676475 05/10/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0760 the evening (to be administered between 4:00pm and 6pm). Level of Harm - Minimal harm or potential for actual harm 1) Apixaban Oral Tablet 5 MG(Apixaban): Give 1 tablet by mouth two times a day for anticoagulant. Residents Affected - Some Observation and interview on 05/10/24 1:30 p.m., revealed Resident #9 was in wheelchair relaxing at the reception area of the facility. He stated he stated he was unable to remember if he missed any medications on any day in that week. During a telephone interview on 05/10/24 at 5:30 p.m., LVN A stated she worked at the facility in the evening shift (6pm to 6am) as Charge Nurse, also had the responsibility of administering medications. She stated, administering the evening medications was the responsibility of the morning shift nurse (6am to 6pm) and the evening shift nurse administer the medications scheduled for night and next day morning. LVN A stated she worked on 05/01/24 and 05/07/24 in the evening shift and did not administer the evening medications to the residents assigned to her on those days. She stated she assumed the day nurse administered those medications on or before 6pm as her duty starts from 6:01pm. She stated for keeping residents' illnesses under control they required the medications as ordered by the MD. LVN A stated she was not instructed to administer the evening medications. During an interview on 05/10/24 at 2:00pm the ADON stated she checked the MAR of Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident to #9, and it was revealed, on 05/01/24 and 05/07/24, LVN A was assigned to those residents, and they did not receive the medications scheduled in the evening. ADON stated LVN A was on suspension as part of disciplinary action (reasons other than medication error). ADON stated LVN A works in the evening shift (6pm to 6am) on PRN basis and it was her responsibility to administer the evening medications to all the residents who were assigned to her while she was on duty. During a second interview on 05/10/24 at 6:00pm, when the investigator reported about LVN A's statement about medication administration responsibility of evening nurse, ADON stated all the nurses and Med Aides supposed to follow the facility policy for medication administration. She added, the practice at the facility was, the nurses and Med Aides who work in the evening shift would administer evening and night medications and the nurses and Med Aides who work in the morning shift (6am to 6pm) administer the daytime medications including morning medications. She stated trainings were provided to all the nurses and Med Aides in this regard in the orientation classes. She added, more over LVN A was the charge nurse and it was her responsibility to ensure all the medications administered correctly. During an interview on 05/10/24 at 5:00 p.m., the NP stated, she practiced as NP for about 30 years and work as the NP at the facility for many years. She said the residents at the facility supposed to receive their medications in the right doses at the right time. When investigator asked about the consequences of the medication omissions on 05/01/24 and 05/07/24, the NP stated, the impact of the omission of medications was depended on the specific circumstances and it was not possible to provide a general statement. She stated, she was familiar with the residents at the facility and none of them were at risk if one or two doses of their evening medications were missed once in a while, she added, however the best practice was adherence to the instructions in the medication orders. During an interview on 05/10/24 at 6:15 p.m., the DON stated it was the responsibility of all the nurses and Med Aides to administer all the medications ordered, irrespective of what shift they worked in. The DON stated, in the PCC the outstanding medication will be alerted, and it was the 676475 Page 8 of 10 676475 05/10/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some responsibility of LVN A to check if any medication is due and administer then as soon as possible. He said it was also her responsibility as charge nurse to report to ADON or DON if there were any concerns related to medication administration. The DON stated the facility was not happy with LVN A in her competency and performance in various areas and was under scrutiny. The management was already in the process of taking disciplinary action against her (Unrelated to the current medication error issue). When investigator asked how the facility ensured that all the medications was administered correctly, DON stated, as daily auditing was not possible, he audited them randomly. Record review of the employee schedule revealed, on 05/01/24 and 05/07/24, LVN A worked at the facility in the evening shift (6pm to 6am) as one of the Charge Nurses. Record review of the in-service records revealed there were no in services on medication administration since 01/01/2024. Record review of undated facility policy Charge Nurse Job Description reflected: Position Purpose: Provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by the certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures. Major duties and responsibilities: Directs the daily activities of the certified nursing assistants in accordance with current federal, state, and local regulations and guidelines and established facility policies and procedures. Transcribes physician orders to medical record and carries out orders as written. Prepares and administers medications as per physicians' orders and observes for adverse effects Provides nursing leadership to nursing personnel assigned to the unit Reports any incidents or unusual occurrences to the supervisor, unit manager, assistant director or nursing or director of nursing and participates in the investigative process as needed. Ensures that there is adequate stock of medications, supplies, equipment and notifies appropriate personnels of needs. Record review of website https://www.nhs.uk/medicines/apixaban , accessed on 05/29/24 reflected: If you stop taking apixaban, the rate at which your blood clots will return to what it was before you started taking it, usually within a day or two of stopping. This means that you may be at increased risk of serious problems like stroke, heart attack, deep vein thrombosis or pulmonary embolism. Record review of website https://my.clevelandclinic.org/health/drugs/21561-gabapentin , accessed on 05/29/24 reflected: Stopping gabapentin suddenly can cause serious problems, including increasing your risk of seizures 676475 Page 9 of 10 676475 05/10/2024 Avir at Madisonville 600 Bacon Street Madisonville, TX 77864

F 0760 Level of Harm - Minimal harm or potential for actual harm (if you are taking gabapentin to control seizures) or not improving your symptoms (if taking gabapentin for other indications). Missing doses may trigger a seizure. Record review of website https://www.webmd.com/drugs/2/drug-1788/depakote-oral, accessed on 05/29/24 reflected: Residents Affected - Some If this medication [Depakote] is used for seizures, do not stop taking it without consulting your doctor. Your condition may become worse if the drug is suddenly stopped Remember to use it at the same time each day to keep the amount of medication in your blood constant. Record review of website https://www.nhs.uk/medicines/levetiracetam, accessed on 05/29/24 reflected: It's important to take your medicine [Keppra] regularly. Missing doses may trigger a seizure. Record review of website https://www.mayoclinic.org/drugs-supplements/isosorbide-dinitrate-oral-route-sublingual, accessed on 05/29/24 reflected: Abrupt cessation of short-term continuous treatment with isosorbide dinitrate may cause a rebound increase in silent myocardial ischemia (heart muscle doesn't receive enough blood) in patients with stable angina pectoris (Severe chest pain). 676475 Page 10 of 10