Health inspection·June 23, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for two (Residents #15 and #32) of six residents reviewed for PASRR. The facility failed to ensure an accurate additional PASRR Level I screening was completed for Residents #15 and #32. This failure could place residents at risk of not receiving necessary care and services in accordance with individually assessed needs. Findings included: Resident #15 Record review of Resident #15's admission record revealed a [AGE] year-old resident admitted on [DATE]. The admission record documented he had diagnoses including dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) diagnosed 7/30/2020, psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) diagnosed 7/30/2020, mood disturbance (affective disorders are a set of psychiatric diseases, also called mood disorders: the main types of affective disorders are depression, bipolar disorder, and anxiety disorder) diagnosed 7/30/2020, anxiety (characterized by excessive fear and worry and related behavioral disturbances) diagnosed 7/30/2020, major depressive disorder (mental health disorder having episodes of psychological depression) diagnosed 1/27/2020, and PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) diagnosed 1/27/2020 Record review of Resident #15's medication record revealed he had prescriptions including Lidocaine external patch applied topically every 12 hours as needed for pain, Hydralazine HCI 100mg by one tablet three times daily for blood pressure, Lasix 20mg tablet once daily for edema, and Prednisone 5mg one tablet daily for inflammation. Record review of Resident #15's quarterly MDS dated [DATE] with an ARD of 6/10/2023 revealed a BIMS score of 13 indicating a minimal cognitive delay. The MDS revealed Resident #15 he had no behavioral indications of psychosis, behaviors affecting others, rejection of care, or wandering or elopement behaviors. Per the MDS Resident #15 required two-person extensive assistance with bed mobility, Page 1 of 21 676479 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transfers, toileting, and personal hygiene, supervision and two-person assistance with locomotion, and was totally dependent on two-person assistance with dressing. Per the MDS, he was totally dependent on staff for oral hygiene, toileting, bathing, dressing, and putting on and taking off footwear. The MDS revealed he was dependent on staff for rolling, transferring from sitting to lying positions, movement from sitting to standing, transferring from bed to chair or chair to bed, and toileting transfers, and he used a wheelchair. The MDS documented Resident #15 was frequently incontinent of bladder and always incontinent of bowel, and he was not using a toileting program. The MDS noted no weight gain of more than 5% in a month. The MDS revealed he was at risk of developing pressure ulcers or injuries, but he did not currently have any. Per the MDS, Resident #15 had been administered diuretic medication seven of the previous seven days. The MDS documented Resident #15 received no therapeutic services. Record review of Resident #15's care plan revealed a focus on Resident #15's psychosocial wellbeing problem related to his anxiety with an intervention of removal from conflict to a sav environment for calming and venting feelings. The care plan included a focus on his self-care deficit with interventions including assistance with bathing, bed mobility, dressing, grooming, hygiene, incontinence care, mobility, and transfers. The care plan revealed a focus on Resident #15's dementia with interventions including a consistent routing, medication administration, and use of yes or no questions. The care plan revealed a focus on his memory plan with interventions including notification of change in condition, provision of choices, ensure voices are heard. The care plan revealed a focus on Resident #15's problematic manner of behaviors characterized by ineffective coping, verbal aggression, and loss of control with interventions including provision of additional time to process directions and requests, approaching from in front, ensuring staff do not express anger or impatience, removal from aggressive situations. Record review of Resident #15's PASRR 1 evaluation dated 12/6/2019 revealed the form was completed by the individual with power of attorney. The evaluation documented he had no mental illness, intellectual disabilities, and/or developmental disability in sections C0100, C0200, and C0300 of the form. Record review of Resident #15's PASARR 1 evaluation dated 1/27/2020 revealed the form was completed by Resident #15's family member. The evaluation documented he had no mental illness, intellectual disabilities, and/or developmental disability in sections C0100, C0200, and C0300 of the form. Record review of Resident #15's PASARR 1 evaluation dated 6/11/2020 revealed the form was completed by a director of case management at an acute care facility. The evaluation documented he had no mental illness, intellectual disabilities, and/or developmental disability in sections C0100, C0200, and C0300 of the form. Record review of Resident #15's Mental Illness/Dementia Resident Review form (Form 1012) dated 6/22/2023 revealed it was completed a physician. The form documented Resident #15 was not eligible for services due to a primary diagnosis of dementia. The form further documented Resident #15 was diagnosed with another unnamed mental illness disorder on 1/27/2020 and a mood disorder such as bipolar disorder, major depression, or another mood disorder on 7/30/2020. The form's section D related to nursing facility action, but it was not completed and had no signature. Observation on 6/20/2023 at 9:21 AM of Resident #15 revealed he was lying in his bed watching television. Resident #15 appeared clean and appropriately dressed. 676479 Page 2 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0644 Resident #32 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #32' admission record revealed a [AGE] year-old resident admitted [DATE]. The admission record documented his diagnoses included cerebral infarction (a loss of blood flow to part of the brain-a stroke), bipolar disorder (serious mental illness characterized by extreme mood swings) diagnosed 1/14/2021, altered mental status (an abnormal state of alertness or awareness), major depressive disorder recurrent (mental health disorder having episodes of psychological depression) diagnosed 11/2/2020, schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder) diagnosed 7/28/2020, and transient ischemic attack (brief stroke-like attack wherein symptoms resolve within 24 hours). Residents Affected - Few Record review of Resident #32' medication record he had prescriptions including Trazadone 50mg ½ tablet (25mg) once daily at bedtime for major depressive disorder related insomnia and Carbamazepine 100mg twice daily for bipolar disorder and major depressive disorder. Record review of Resident #32's orders record revealed an indefinite order for psychological treatment dated 6/22/2021. The record documented an order for Carbamazepine therapy every six months dated 12/1/2020. Record review of Resident #32's quarterly MDS dated [DATE] with an ARD of 4/20/2023 revealed a BIMS Of 15 indicating minimal to no cognitive delay. The MDS documented he had no behaviors or indications of psychosis, no behaviors affecting others, no rejection of care, and no wandering or elopement behaviors. The MDS revealed Resident #32 was administered antidepressant and diuretic medications seven of the seven days prior to the assessment. Record review of Resident #32's care plan dated 4/4/2023 revealed a focus on his risk of social isolation due to depression, PTSD, and bipolar disorder with interventions including medication administration, psychological consultations, and monitoring for signs or symptoms of depression. The care plan documented a focus on his hypnotic/sedative mediations with interventions including monitoring for side effects, education on the medication, and monitoring for the targeted behaviors. Record review of Resident #32's PL1 dated 7/22/2020 revealed it was completed by his family member. The PL1 documented he had no mental illness, intellectual disability, and developmental disability in sections C0100, C0200, and C0300 of the form. Record review of Resident #32 Mental Illness/Dementia Resident Review form (Form 1012) dated 6/22/2023 revealed it was completed by a physician. The form documented Resident #15 was eligible for services as there was not a primary diagnosis of dementia. The form further documented Resident #15 was diagnosed with another unnamed mental illness disorder on 8/9/2020, schizoaffective disorder on 8/9/2020 and a mood disorder such as bipolar disorder, major depression, or another mood disorder on 11/2/2020. The form's section D related to nursing facility action noted a new positive PL1 was submitted on 6/22/2023. Interview on 6/23/2023 at 8:41 AM with Resident #32 said he had received therapy in the past. Resident #32 said he only received therapy when it was approved by the VA. Resident #32 said the VA typically approved therapy for two weeks at a time. Resident #32 said when he received therapy it was very beneficial. Resident #32 said he was not currently receiving therapy. Resident #32 the VA had stopped his therapy benefits. Resident #32 said he would like therapy because it was helpful. 676479 Page 3 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 6/22/2023 at 3:02 PM with The MDS Nurse revealed she was an LVN and had been employed by the facility for a little over one month. The MDS Nurse said her primary assignments were to complete the MDS assessments, some interviews, and ensure the PASARR 1 was completed for the residents entering the facility. The MDS Nurse said the PL1 was completed prior to the resident's admission in the facility. The MDS Nurse said if the PL1 was positive for ID, MD, or DD the local health authority would evaluate the resident for any services required. The MDS Nurse said if the resident was eligible for services, she would coordinate a meeting with the resident's family to coordinate services. The MDS Nurse said if a resident received a new diagnosis of ID, MD, or DD while in care at the facility, she would complete a new Mental Illness/Dementia Resident Review (Form 1012) to determine if a new PL1 was required. The MDS Nurse said if a new PL1 was required the facility would complete it, the local authority would evaluate the resident, and services may be offered. The MDS Nurse said the Form 1012 should be completed as soon as a new ID, MD, or DD diagnosis was determined. The MDS Nurse said a new Form 1012 should have been completed for both Resident #15 and Resident #32 prior to 6/22/2023. The MDS Nurse said Resident #15 would have been ineligible for a new PL1 due to a primary diagnosis of dementia, but Resident #32 would have needed a new PL1. The MDS Nurse said if the PASARR was not completed appropriately a resident may not receive services he/she were eligible for. Interview on 6/22/2023 at 3:32 AM with the DON and Admin, the DON said if a resident was admitted with a positive PL1, it was the responsibility of the local health authority to evaluate the residents. The DON said the local health authority determines if services are needed and the facility coordinates those services. The Admin said if a resident received a new diagnosis of ID, MD, or DD, they would not be eligible for a new P1 if the Form 1012 indicated a primary diagnosis of dementia or Alzheimer's disease, The DON said if a resident did not have the PASARR process completed appropriately he/she/they may not receive services necessary. The Admin said he did not know Resident #15 and Resident #32 had required a new Form 1012 and Resident #32 required a new PL1. The Admin said the Form 1012's for both Resident #15 and Resident #32 should have been completed prior to 6/22/2023. Record review of the facility's undated Preadmission Screening and Resident Review (PASRR) policy read in part .ensure each resident in a nursing facility is screened for mental disorder (MD) or intellectual disability (ID) prior to admission and that the individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs ., .the PASRR will be completed prior to admission ., .the PASRR determines the level of services required and specialized services ., and .a positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority known as Level II PASRR . . 676479 Page 4 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder and had a catheter upon admission, received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #29 and #50) of 3 residents reviewed for incontinent care. -The facility failed to ensure Resident #29's foley bag and tubing was not placed on the floor. -The facility failed to ensure CNA C followed appropriate infection control procedures during foley care for Resident #29. -The facility failed to ensure Resident #50's foley bag was positioned below the bladder. These failures could place residents at risk for pain, infection, injury, and hospitalization. Findings included: Resident #29 Record review of Resident #29's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), gastrostomy (used to provide a route feeding to the stomach ) dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #29's admission MDS assessment, dated 05/22/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he required extensive assistance with one to staff assist with all ADL. The resident had an indwelling catheter. Record review of Resident #29's care plan initiated 05/17/22 and revealed the following: Resident#29 have indwelling foley catheter 18fr 10cc. I am at risk for complication. Intervention: check tubing for kinks each shift. Foley catheter care with perineal wipes and/or soap and water every shift and as needed. Record review of Resident # 29's order summary report for June 2023 reflected: foley catheter 18 FR 10 cc, change monthly and PRN one time a day starting on the 20th and ending on the 20th every month related to pressure ulcer of sacral region, stage IV, date initiated 0619/23. Observation on 06/20/23 at 10:45 a.m., it revealed Resident # 29's foley bag, foley cover and tubing were on the floor. Interview on 06/20/23 at 10:51 a.m., RN P said she observed Resident #29's Foley bag and tubing on the floor. She said the bag should not touch the floor to prevent infection. She said she had skills checked off for Foley care. Interview on 06/21/23 at 12:30 p.m., the DON said Resident #29's Foley bag and tubing should not 676479 Page 5 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0690 touch the floor because it was an infection control issue which could cause UTI for the resident. Level of Harm - Minimal harm or potential for actual harm Observation on 06/21/23 at 2:24 p.m., Resident 29's's Foley care was provided by CNA A, and CNA C revealed CNA C did not clean the Foley catheter during Foley care. Residents Affected - Some Interview on 06/21/23 at 2:50 p.m., CNA A said CNA C did not clean the catheter when they provided foley care to Resident #29. She said Resident #29 could get an infection if the germs traveled back to the resident penis because it was inserted into his penis. Interview on 06/21/23 at 2:58 p.m., CNA C said she forgot to wipe the tube inserted into Resident #29, and it would be an infection control issue. CNA C said she did the skill check-off on Foley. She said she did not know why she did not clean the tube because it could cause a severe infection for Resident #29. Resident #50 Record review of Resident #50's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (a condition that affects brain and spinal cord), neuromuscular dysfunction of bladder (ack of bladder control due to brain, spinal cord or nerve problem ) dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #50's quarterly MDS assessment, dated 05/27/23, revealed the BIMS score was 06, which indicated severely impaired cognition. Further review of the MDS revealed he required extensive assistance with one to staff assist with all ADL. The resident had an indwelling catheter. Record review of Resident #50's care plan initiated 05/12/23 and revealed the following: Resident #50 required an indwelling foley catheter 16fr 10cc related to diagnosis of neuromuscular dysfunction of bladder. Intervention: change catheter per facility protocol or physician order. Record review of Resident #50's order summary report for June 2023 reflected: Foley catheter 16 FR 10 cc, change as needed related to neuromuscular dysfunction of bladder, Observation on 06/21/23 at 7:00 a.m. revealed Resident #50's was sitting in the dining room with two other residents on the same table, and her foley bag was hung on top of her wheelchair close to the resident's upper back. Observation on 06/21/23 at 7:00 a.m., RN A said the aide had placed Resident #29's Foley on the backrest of the wheelchair. She said the bag was hung above the bladder, and urine would flow back to Resident #50's bladder, which could cause a urinary tract infection. She said she had in-service and skills checked off for Foley care. She said the nurse monitored the aides and ensured they cared for the residents. She said she was unaware the foley bag was hung on the back of the wheelchair until now. During an interview on 06/21/22 at 1:29 p.m., the DON said Resident #50's Foley bag should be hung below the bladder, not above, so the urine would not flow back to the resident's bladder, which could cause infection. She said the ADON made random checks to monitor the nurse and the aides to ensure they provided care for the residents. 676479 Page 6 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0690 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy on Cather care for Male Revised: March 2023 read in part . Purpose . it is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter using proper technique . Procedure #12 . anchor catheter, hold securely and cleanse the tubing from the urethral open downwards . Residents Affected - Some . 676479 Page 7 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #13) of 3 residents reviewed for respiratory care. Residents Affected - Few - The facility failed to provide Resident #13 appropriate nasal cannula for oxygen administration to prevent the prongs from hurting the resident's nostrils. - The facility failed to prevent Resident #13 from adjusting the oxygen setting on the concentrator. These failures placed residents who received oxygen therapy at risk of respiratory complications. Findings included: Record review of Resident #13's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia (loss of cognitive function, thinking,), chronic obstructive pulmonary disease, chronic respiratory failure, and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #13's quarterly MDS assessment, dated 06/14/23, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS did not indicate the resident was on oxygen. Record review of Resident #13's undated care plan revealed Resident #13 required oxygen therapy to impaired gas exchange as evidenced by diagnosis of chronic obstructive pulmonary disease. Record review of Resident #13's Nurse Administration Record for June 2023 read continuous oxygen 3 liters per N/C every shift for oxygen, nurses signed-off on it. Record review of Resident #13's order review report for June 2023 read continuous oxygen 3 liters per N/C every shift for oxygen. Observation and interview on 06/20/23 at 11:12 a.m., revealed Resident #13's oxygen was set to 3.5, and Resident #13 said his oxygen should be set on 4L. Interview on 06/21/23 at 8:10 a.m., revealed the concentrator was set at 3.5 liters. RN A said she had not checked the setting on the concentrator, and she needed to know how many liters of oxygen the resident concentrator should be set, and she would find out and get back to the surveyor. She said the nurses should check the oxygen setting on the concentrator and sign off on the MAR. During an observation on 06/22/23 at 12:11 p.m. revealed Resident # 13's O2 was set at 3.5 L on the concentrator. During an interview on 06/22/23 at 12:18 p.m., Resident #13 said he changed the settings on the concentrator because prongs on the NC hurt his nose because they are long. He said it said when they changed from the shorter prongs, and he had told the nurses, and none of them had done anything about 676479 Page 8 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few it. He said he increased the oxygen because he did not put the prongs all the way into his nostrils. Resident #13 said he told the nurses not to change the setting until they provided the old NC, which had been months. Resident #13 said he was not sure if he was getting more oxygen or not, but he was comfortable. During an interview on 06/22/23 at 12:19 p.m. RN M said he checked Resident #13 oxygen setting this morning but needed help remembering where it was set or what his order was on the MAR. RN A checked the setting with the surveyor and said it was on 3.5 L. RN M said, Let me tell you, I just checked the concentrator, and the resident had a NC but did not notice if it was inside his nostrils. He said he was unaware the resident had a problem with NC because this was his day working on POD A. He said if the resident kept changing the oxygen to a higher setting, it could cause the resident not to clear carbon dioxide. Interview on 06/22/23 at 12:32 p.m., LVN W said nurses had a check off on their screen, showing how much oxygen Resident # 13 should be on. She said if the resident complained the NC was hurting his nose, the nurse should get him another one, and if the facility did not have it, she would get with central supply to see if the facility would buy another type of NC. LVN W said the oxygen should not change without a doctor's order because it is medication. She said if they had an emergency, they could put oxygen on a resident, call 911, and notify the doctor. She said the adverse outcome would be that if the resident could not process the 02, it would increase the C02 level. LVN W said the nurse had not told her Resident #13 was adjusting his oxygen because the nurses monitored Resident #13 oxygen each shift. Interview on 06/22/23 at 4:46 p.m., the DON said the nurses should be checking the setting on the concentrator for Resident #13 because they signed off in the MAR. She said oxygen should only be changed with a doctor's order, and the nurses should have educated Resident #13 not to adjust the setting on the concentrator and the adverse reaction. She said the nurses had not told her Resident #13 was changing the oxygen, and the NC prong was hurting his nostrils. Record review of the facility policy on oxygen administration revised: February 2015 read in part . correct technique and standards of practice will be used with oxygen administration . . 676479 Page 9 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 28 opportunities, which involved 1 (Residents #29) of 5 residents reviewed for medication errors. Residents Affected - Some -RN A failed to administer three medications scheduled for 8:00 a.m. during Resident #29's medication administration through a g-tube. This failure could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings include: Record review of Resident #29's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), gastrostomy (used to provide a route feeding to the stomach) dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #29's admission MDS assessment, dated 05/22/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he required extensive assistance with one to staff assist with all ADL. The resident had a g tube. Record review of Resident #29's care plan initiated 05/17/22 and revealed the following: Resident#29 required tube feeding related to dysphagia and CVA. Intervention: flush tubing with 30 cc of water before and after medication administration. Record review of Resident # 29's order summary report for June 2023 revealed -Omeprazole powder, give 40mg via g - tube imitated 05/23/23 -Vitamin C give 1 tab via g - tube one tome a day via g - tube -Lokelma oral packet 5 gram give 1 packet via g- tube one a day related to hyperkalemia-initiated date 06/01/23. Every shift administers 10 to 15 ml of water between each medication, initiated date 05/15/23. Observation on 06/21/23 at 7:10 a.m. revealed RN A prepped and administered medication for 8:00 a.m. to Resident #29 but did not administer the following three medications: Lokelma oral packet of 5 grams give one packet, vitamin C, and omeprazole 40 mg was not given because it was left in the portion cup and in the syringe which was used to administer the medications. Interview on 06/21/23 at 1:31 p.m., the DON said if the medication was not given when it was scheduled, it would be considered a medication error, and Resident #29 may not get the desired outcome. Record review of the facility gastrostomy tube medication administration revised October 2012 read 676479 Page 10 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0759 in part . medication to be administered through gastrostomy tube per physician' order . Level of Harm - Minimal harm or potential for actual harm Record review of the facility Omnicare, a CVS health company read in part . facility staff should also refer to the facility policy regarding medication administration . Residents Affected - Some Record review of the facility medication administration competency revealed RN A signed the competency on 4/13/23. . 676479 Page 11 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication rooms (Medication Rooms) 1 out of 2 nursing medication carts (nurse medication cart for POA A), and residents reviewed for medication storage. - The facility failed to ensure nurse cart did not have discontinued, opened undated and opened medication not stored in its original packet. - The facility failed to ensure the Medication Rooms (POD D and POD C) did not contain expired medication, and unlabeled medication not stored in he delivery packet - The facility failed to ensure RN A did not leave medications in a medication cup on top of the unlocked medication cart and unattended. - The facility failed to ensure RN A did not leave breathing treatment medication for Resident #13 in room for the resident to administer himself. These failures could place residents at risk of adverse medication reactions and infections. Findings Include: Observation on 06/22/23 at 2:18 p.m. with LVN W revealed the following medication in the nurse's cart: -Albuterol sulfate metered was not in the original packet which it was delivered in, -2 Albuterol sulfate HFA was opened, and it was not dated with open date, -E Swab transport system expired 05/03/23, -Sorbitol 15 gm/60 ml was discontinued and left in the cart. Interview on 06/23 at 2:20 p.m., LVN W said discontinued medication should be taken out of the cart because you do not want to give any resident discontinued medication. She said medication should be dated when opened to prevent residents from getting expired medication. She said the test result could be affected, and it might lead to misdiagnosis. Interview on 06/22/23 at 2:23 p.m., RN M said medications are dated to prevent giving residents expired medication. He said discontinued medication should be pulled from the cart to prevent the medication from being administered by mistake, which would cause medication error or may have a negative outcome for the resident. Observation on 06/22/23 at 2:40 p.m., with LVN E and LVN L for Medication room in D POD revealed the following expired medication: 676479 Page 12 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0761 -Accu-check Avia test strips expired 04/07/23 and there was 7 boxes, Level of Harm - Minimal harm or potential for actual harm -Accu-check 30 strips 10 boxes expired 04/27/23, Residents Affected - Some -Fluorouracil cream was discontinued and it was in the shelf in the medication room, -Diclofenac sodium topical gel was not in the delivery packet and it did not have instructions on application instruction, -Diclofenac sodium topical 1% expired 06/17/23, -Diclofenac sodium topical 1% expired 04/15/23 Interview on 06/22/23 at 2:53 p.m., LVN E said medications that were discontinued should be placed in the discontinued box, and they should not be on the shelf to prevent the medications from being administered by mistake. She said all medications should be stored in their original packets to know the instruction for use, such as the temperature. Interview on 06/22/23 at 2:56 p.m., LVN L said the ADON or the pharmacy nurse should pull expired medications from the cupboard to prevent them from being administered to the residents because the medication had lost their potency. She said when a medication was discontinued, it must be pulled from the cart and medication room and given to the pharmacy nurse or put in the discontinued bin. She said if the medication was not pulled, the staff might give it by mistake, and it becomes a medication error. She said the medication should be stored in its delivered packet because it has the resident name and instructions; if it was not in its original packet, it could be given to the resident which it did not belong or the wrong dose. LVN L said the medication would not be effective. Observation on 06/22/23 at 3:10 p.m., with LVN Y and RN T in the Medication room in C POD revealed the following expired medication: -Levetiracetam oral solution 100mg expired 04/25/23, -Ultratuss(guaifenesin) expired 05/11/23, -two Artificial tears expired 04/10/2. At the same time, the following over the counter medications were open and inside the cupboard: -Walgreen Vitamin D3, -Daily Vitamin formula and Iron, -Vitamin E 180mg(400IU), -Century 21st D3 1250 mcg (50,000IU). Interview on 06/22/23 at 3:20 p.m., RN T said expired medications should be placed in the bin or given to the pharmacy nurse. She said the charge nurse should pull the medication from the self. RN T said expired medication could be administered to a resident if it was not pulled. She said the resident could have advised reaction action depending on what the medication was and decreased 676479 Page 13 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0761 effectiveness. Level of Harm - Minimal harm or potential for actual harm Interview on 06/22/23 at 3:49 p.m., LVN Y said opened over-the-counter medication should not be in the medication room because they do not know when it was opened, and the facility does not every carry those brands of over-the-counter medication. Residents Affected - Some Interview on 06/22/23 at 5:03 p.m., the DON said the expired medication should be placed in an expired medication bin. She said it should be pulled so the nurses would not administer expired medication. She said if the expired medication was administered to a resident, it could cause an adverse reaction depending on the medication type. She said the medication should be stored in the original delivery packet because the order, instructions, and the resident's name are printed on the packet. Observation on 06/21/23 at 7:12 a.m. revealed that RN A left medications on top of the unlocked medication cart and went to the nursing station. -7:16 a.m. RN A left the unlocked medication cart with medications on the cart and went to the nursing and got a spoon. -7:20 a.m. RN A took 1 cup of medication into the resident room three seperate times until all the medications were in Resident #29's room. During the trips to the resident's room the medication cart was unlocked and had medication on top of the cart. -7:22 a.m. RN A left the cart unlocked and left the cart. Interview on 06/21/23 at 7:53 a.m., RN A said she was nervous, so she left the cart unlocked and the medications on top of the cart. She said the residents were walking around in the dining area close to the unlocked cart and medications on top of the cart. She said any resident could have taken the medication, and it could make the resident sick. She said the cart had all the medication the nurse should give for POD A. Observation on 06/12/23 at 8:07 a.m., RN A kept ipratropium bromide and albuterol sulfate 0.5/3mg per 3ml on Resident # 13's bedside table, and the resident took it and put it in his pocket. Resident #13 said he would administer it when he wanted. Interview on 06/21 at 8:07 a.m., RN A said she was unsure if Resident #13 could administer the breathing treatment himself. However, she left the medication for the resident because the nurses had been doing that. Interview on 06/21/23 at 1:04 a.m., the DON said RN A should not have left the cart unlocked and medication on top of the cart and walked away because the residents could get into the cart or taken the medication on top of the cart. She said the resident could have several side effects, such as a lower heart rate. She said she was unsure if Resident # 13 could administer his medication. Still, RN A should not have left medication for the resident without training on self-medication administration. Record review of the facility policy Omnicare, a CVS health company for medication and expiration dating of medications read in part procedure 3.3 . facility should ensure all medications . are securely stored in a locked cart . # 4 . facility should separate expired medication and stored separate from other medications until destroyed . #5 . facility should record the date opened on the primary 676479 Page 14 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0761 Level of Harm - Minimal harm or potential for actual harm medication container . #6 . facility should destroy and reorder medications . damaged or missing label . #13 .1 Bedside medication storage: . facility should not administer/provide bedside medications without physician/prescriber order . . Residents Affected - Some 676479 Page 15 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed properly for 2 of 2 dumpsters reviewed for garbage disposal. Residents Affected - Few -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 06-20-23 at 8:30 am, with the Food Service Manager revealed the facility's dumpster area, which was in the lot behind the dietary department had a 2 commercial -size dumpsters and the lids and doors were opened. Interview on 06-20-23 at 9:00 am, with the Food Service Manager she stated the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She also stated that she is responsible for all requirements be met in the Food Service Department. She will in-service the dietary staff on following Policy and Procedure for Garbage Disposal Record review of the facility policy and procedure dated June 1, 2019, revealed that outdoor storage shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside. . 676479 Page 16 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0880 Provide and implement an infection prevention and control program. 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 did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 6 Staff (CNA S, RN A, Dietary Aide O, and Laundry Aide H) reviewed for infection control. Residents Affected - Some - The facility failed to ensure CNA S followed proper hand hygiene during hydration. - The facility failed to ensure RN A followed proper hand hygiene and infection control procedure during gtube medication administration for Resident #29. - The facility failed to ensure RN A followed proper hand hygiene and infection control procedure during ACCU CHECK for Resident #58, Resident #75, and Resident #92. - The facility failed to ensure Dietary Aide O did not wear gloves in the hallway. - The facility failed to ensure Laundry Aide followed proper hand hygiene when he demonstrated hand washing. These deficient practices could affect residents and place them at risk for infection, and reinfection. Findings include: Observation on 06/20/23 at 9:40 a.m. revealed, CNA S came out of room [ROOM NUMBER] and went into room [ROOM NUMBER] without washing her hand. Then she came out of the room with the resident water pitcher, went into the hydration room, filled the pitcher with ice and water, and returned to room [ROOM NUMBER]. CNA S came out of room [ROOM NUMBER] and still did not sanitize her hand. Interview on 06/20/23 at 9:46 a.m., CNA S said she should have sanitized her hand when she came out of one resident room before she went into another's and before she filled the water pitcher with ice and water. She said hands are sanitized to prevent the transfer of germs from one resident to another. She said she had in service on hand washing. Observation on 06/21/23 at 7:10 a.m., RN A did not sanitize or wash her hand before she popped medications for Resident #29. Observation on 06/21/23 at 7:25 a.m., RN A did not wash her hand before she donned gloves or disinfect the stethoscope bell before she auscultated and checked for g-tube placement. After administering the medication, she washed her hands and turned off the water faucet with her wet hands. Interview on 06/21/23 at 8:00 a.m., RN A said she was nervous and forgot to wash her before she started taking medication from the container and when she assessed Resident #29 g tube before she administered the medications. She said she forgot to dry her hands before she turned off the water tap. She said she could transfer germs to Resident #29 because she did not use proper infection control measures. 676479 Page 17 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0880 Level of Harm - Minimal harm or potential for actual harm Observation on 06/21/23 at 8:07 a.m., RN A administered inhalation treatment to Resident #13 in his room and left the resident's room without washing or sanitizing her hands. Interview on 06/20/23 at 8:10 a.m., RN A said she forgot to wash or sanitize her hand after she provided inhalation treatment for the resident. She said she could transfer germs to another resident. Residents Affected - Some Observation and interview on 06/20/23 between 8:13 a.m. and 8:29 a.m., RN A wore one set of gloves without washing her hands or changing her gloves, provided an accu-check (blood sugar check) on three residents (Resident #58, Resident #75, and Resident #92) and administered insulin to Resident #58. RN A carried a box of alcohol wipes with lancets and a container of strips, and she placed it on the residents' tables without a barrier. Interview on 06/20/23 at 8:30 a.m., RN A said she forgot and did not realize she was wearing the same gloves when she did the accu - checks for the three residents. She placed the box on the residents' table and the dining room table, which could have transferred germs from one resident to another, an infection control issue. She said she should have washed her hands and checked gloves from one resident to another and disinfected the glucometer between each resident and had a barrier on the tables. She said she had skills checked off on blood sugar checks. Interview on 06/21/23 at 12:18 p.m., the DON said RN A should sanitize or wash her hands before she pouched medication from the blister or container Resident #29. She said she contaminated her hands when she turned off the water faucet with her wet hands. She said RN A should have removed her gloves and washed her hands or sanitized them before going to another resident because of infection control. Observation on 06/21/23 at 8:52 a.m., it revealed Dietary Aide O was walking in the hallway in POD C and had gloves on her hands. Interview on 06/21/23 at 8:52 p.m., Dietary aide O said she was not supposed to wear gloves on the hall because it was an infection control issue. Dietary aide O said she had a lot of work to do, so she forgot to remove her gloves and just finished serving all three halls in POD C. She said she had in service on PPE and hand washing. Interview on 06/21/23 at 3:52 p.m., the Dietary manager said Dietary aide O should not have worn gloves on the hall because of cross-contamination. Observation and interview on 06/21/at 3:40 p.m., it was revealed Laundry aide H washed his hands and dried his hands with a paper towel. He used the same paper towel with which he dried his hands, turned off the water faucet, and continued using the same paper towel to dry his hands until he got to the trash can and disposed of the paper towel. Laundry aide H shrugged his shoulder when asked why he used the same wet paper towel and continued to use it. He also did not respond when asked if he had in-service on hand hygiene. Interview on 06/21/23 at 3:48 p.m., the Laundry supervisor said Laundry aide H should have used a dry paper towel when he turned off the water tap which would have prevented his hands from being contaminated. Observation and interview on 06/21/23 at 3:50 p.m., it revealed three clear plastic bags with red napkins and four red napkins that were not in the plastic bag on the floor in the dirty section of 676479 Page 18 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the laundry room. Laundry aide H said the kitchen staff placed the napkins on the floor, which should be placed in the gray bin; he said it was an infection control issue. Interview on 06/21/23 at 3:56 p.m., the Dietary manager said her staff brought the napkins to the laundry room and placed it on the floor. She said the staff should not have left it on the floor because they have a trash can (gray) for the staff to put the napkin in. She said it was an infection control issue. Interview on 06/22/23 at 4:50 p.m., the DON said CNA S should wash or sanitize her before she left a resident room and wash or sanitize when she entered another resident to prevent the spread of germs. Record review of the facility policy on hand hygiene Revised: February 2020 read in part . it is the policy of the is facility that staff will perform hand hygiene to aide in the prevention of the transmission of infection . procedure #4 . pat your hand dry with paper towel and discard . #5 . turn off the faucets with a clean, dry towel and discard . Record review of the facility policy on gastrostomy tube medication administration Revised: October 2012 read in part . procedure: . #1 . wash or sanitize your hands . #4 . clean the bell of the stethoscope with an alcohol prep . Record review of the facility competency gastrostomy tube medication revealed RN A signed the paper on 04/13/23. . 676479 Page 19 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the call system was accessible to the resident at each resident's bedside for one (Resident #15) of twenty-two residents reviewed for call lights. Residents Affected - Few -The facility failed to ensure the call light system in Resident #15's room was in a position which was accessible. This failure could place residents at risk of being unable to obtain assistance in the event of an emergency. Findings include: Record review of Resident #15's admission record revealed a [AGE] year-old resident admitted on [DATE]. The admission record documented he had diagnoses including dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) diagnosed 7/30/2020, psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) diagnosed 7/30/2020, mood disturbance (affective disorders are a set of psychiatric diseases, also called mood disorders: the main types of affective disorders are depression, bipolar disorder, and anxiety disorder) diagnosed 7/30/2020, anxiety (characterized by excessive fear and worry and related behavioral disturbances) diagnosed 7/30/2020, cerebrovascular disease (conditions that affect blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis(weakness on one side of the body), chronic kidney disease (a gradual loss of kidney function), Wegner's granulomatosis (autoimmune multisystem disease, which causes inflammation of blood vessels in nose, sinuses, throat, lungs and kidneys) with renal (kidney) involvement, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), anemia (deficiency of healthy red blood cells in blood), arteritis (inflammation of blood vessels), hypertension (high blood pressure), cerebral infarction (a loss of blood flow to part of the brain-a stroke), delusional disorders (fixed, false conviction in something that is not real or shared by other people), gastrointestinal hemorrhage (bleeding that occurs from the digestive tract, from the mouth to the rectum), adjustment disorder (short term condition arising due to difficulty in managing the stressful life changes), hyperlipidemia (high cholesterol), muscle weakness, lack of coordination, muscle wasting (loss of muscle leading to its shrinking and weakening Loss of muscle leading to its shrinking and weakening ) and atrophy (progressive and degeneration or shrinkage of muscles or nerve tissues), dysphagia (difficulty in swallowing food or liquid), dysarthria (difficulty in speech due to weakness of speech muscles), major depressive disorder (mental health disorder having episodes of psychological depression) diagnosed 1/27/2020, PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) diagnosed 1/27/2020, and insomnia (trouble falling and staying asleep). Record review of Resident #15's quarterly MDS dated [DATE] with an ARD of 6/10/2023 revealed a BIMS score of 13 indicating a minimal cognitive delay. The MDS revealed Resident #15 he had no behavioral indications of psychosis, behaviors affecting others, rejection of care, or wandering or elopement behaviors. Per the MDS Resident #15 required two-person extensive assistance with bed mobility, transfers, toileting, and personal hygiene, supervision and two-person assistance with locomotion, and was totally dependent on two-person assistance with dressing. Per the MDS, he was totally dependent on staff for oral hygiene, toileting, bathing, dressing, and putting on and taking off footwear. The 676479 Page 20 of 21 676479 06/23/2023 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS revealed he was dependent on staff for rolling, transferring from sitting to lying positions, movement from sitting to standing, transferring from bed to chair or chair to bed, and toileting transfers, and he used a wheelchair. The MDS documented Resident #15 was frequently incontinent of bladder and always incontinent of bowel, and he was not using a toileting program. Record review of Resident #15's care plan revealed a focus on his call light use with interventions including instructing him on call light use and ensuring the call lights were within reach. Interview on 6/20/2023 at 10:48 AM with CNA A revealed she had been employed by the facility for approximately two months. CNA A said her primary responsibilities as a CNA were to care for the residents, assist them with ADLs, and assist residents with showers. CNA A said the residents' call lights should be placed in a location they can reach and press the button. CNA A said the position of the call light in Resident #15's room was inappropriate. CNA A said the call light should have been placed where he could reach. CNA A said if a resident's call light was not placed in a position the resident could reach the resident may not be able to call for help in an emergency. Observation on 6/20/2023 at 9:21 AM of Resident #15 revealed he was lying in his bed watching television. Resident #15's call light was placed at the end of his bed in a position he could not reach. Interview on 6/20/2023 at 9:21 AM with Resident #15 he said the facility staff often placed his call light where he could not reach it. Resident #15 said the staff responded to call lights when he could call them. He said this made him upset and concerned his needs would not be met when he could not reach the call light. Resident #15 said he did not have other concerns at that time. Interview on 6/20/2023 at 10:51 AM with LVN A, she said a resident's call light should be placed near the resident where a resident can reach it. LVN A said if a resident could not reach a call light, he/she may not be able to call for help in an emergency, and he/she would not be able to ask for help with routine activities. LVN A said the call light in Resident # 15's room was not in a position he could reach. LVN A said the call light should have been placed on bed, near his hands. Interview on 6/21/2023 at 3:05 PM with the DON, she said call lights should be placed where a resident is able to reach them. The DON said the facility expectation was that residents would be able to reach their call lights to call for assistance. Record review of the facility's Call Light System dated October 2019 revealed that the entire facility staff was responsible for implementation. The policy read in part .a functioning call light at each resident's bedside, toilet, and bathing areas to allow residents to call for assistance ., .staff will receive education related to the mechanism of the call light system ., .residents will receive education on how to call for assistance using the call light ., .residents will be evaluated for unique needs and preferences ., .special accommodations will be reflected in the resident's plan of care ., and .staff will report noted call light system problems . 676479 Page 21 of 21