Rapid Recovery Center Of Round Rock

F-F755 - The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of a resident, this resulted in Resident #1 missing dosages of ceftriaxone.

1. Corrective Action for residents affected by the deficient practice:

a. Resident #1 had been discharged from the facility on 7/12/2024.

2. How other residents having the potential to be affected be identified and what corrective action(s) will be taken:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 676440 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676440 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 a. Residents admitted to the facility have the potential to be affected by the identified deficient practice. Education was given to DON and GM by Chief Clinical Officer on 7/18/2024. Inservice will start 7/18/2024 Level of Harm - Immediate and be completed by all fulltime staff by 7/19/2024 and be conducted by director of nursing (DON), general jeopardy to resident health or manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA). Training for all safety new hires, PRN and part time employees will be completed prior to start of shift. Post test will be conducted

after Inservice. Topic will include: Residents Affected - Few i. Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider

ii. Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable -

1. Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs.

2. Contact pharmacy immediately. Nurses & CMAs.

3. Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs.

4. Within 1 hour after notifying DON and/or GM, notify physician to request for alternative orders. ONLY for nurses

5. Document and carry out provider's instructions immediately. ONLY for nurses

iii. Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable -

1. DON Contact information is posted in med room

2. Contact GM Contact information is posted in Med Room

3. Contact assigned provider ONLY for nurses

iv. Contents of medication dispensing machine and IV E-kits - see Attachment A

b. Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message. Inservice will be required to be completed prior to start of shift. There will be post test given and graded by CNO and/or GM

c. Nursing staff initiated a MAR-to-Cart audit of all in-house residents on 7/18/2024 to ensure medications are available and to order/reorder medications that are not available in the medication carts. This will be completed by 7/19/2024.

3. Measures that will be put in place or systemic changes that will be made to ensure the deficient practice(s) does not recur:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 676440 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676440 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 a. The medication lists of all new admissions will be matched with actual medications the following day by DON and or designee starting 7/20/2024 and will be ongoing process. Medications should be available by Level of Harm - Immediate next delivery period and/or within 24 hours of order entry. If a medication is scheduled prior to pharmacy jeopardy to resident health or scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or safety medication delivery machine. Then follow regular delivery for the next dose. If medications are not available

on the medication dispensing machine, the nurses and certified medication aides are expected to call for Residents Affected - Few STAT delivery. List of medications available on the medication dispensing machine was posted by DON on 7/18/2024 in the medication rooms.

4. Monitoring performance:

a. DON and/or designee will complete a daily audit of medications for new admissions, starting 7/20/2024 until 8/1/2024. Then will be reduced to weekly x 2 weeks ending 8/15/2024. Then move to random new admit medication audits until 8/30/2024.

b. If there is missing medication, DON and/or designee will ensure that the notification tree was activated beginning 7/18/2024 and will be ongoing process.

c. Findings will be discussed weekly starting 7/19/2024 between GM, DON and/or designee and VP of clinical operations and will continue weekly until 8/15/2024.

There was an ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called. Findings will also be presented during monthly QAPI meeting x3 months.

The Survey Team monitored the Plan of Removal on 07/19/2024

Observations on 07/19/2024 from 08:30 a.m. to 03:30 p.m., revealed nursing staff received in-service training from GM and DON on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications.

Record review on 07/19/2024 revealed daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents.

Record review on 07/19/2024 revealed ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical

Record review on 07/19/2024 revealed in-services completed for 12 staff on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Further record review revealed graded post-test for staff, no failures.

Interview on 07/19/2024 at 03:41 p.m., LVN C stated she has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN C stated she has taken the post-test and confirmed completion and passed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 676440 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676440 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Interview on 07/19/2024 at 03:47 p.m., RN B stated he has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of Level of Harm - Immediate any missing medications to seek immediate interventions and alternatives, and systematic changes to jeopardy to resident health or assure medications and orders accuracy. RN B stated he has taken the post-test and confirmed completion safety and passed.

Residents Affected - Few Observation and interview on 07/19/2024 at 03:53 p.m., LVN D was observed calling the pharmacy on medications delivery. LVN D stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN D stated she has taken the post-test and confirmed completion and passed.

Interview on 07/19/2024 at 04:09 p.m., CMA A stated she he has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, notifying nurses to follow process of provider notifications to seek immediate interventions and alternatives. CMA A stated

she has taken the post-test and confirmed completion and passed.

Interview on 07/19/2024 at 04:36 p.m., ACNO stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. ACNO stated she has taken the post-test and confirmed completion and passed. ACNO stated daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents completed and will continue.

Phone call Interview on 07/19/2024 at 04:39 p.m., LVN B stated she has taken in-services on 07/19/2024 over phone with DON, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN B stated she has taken the post-test and confirmed completion and passed.

Phone call Interview on 07/19/2024 at 04:43 p.m., LVN A stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN A stated she has taken the post-test and confirmed completion and passed.

Interview on 07/19/2024 at 04:49 p.m., the DON stated the Chief Clinical Officer educated her and the GM

on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 676440 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676440 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ignite Medical Resort Round Rock, LLC 16219 Ranch Road 620 North Austin, TX 78717

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Interview on 07/19/2024 at 04:59 p.m., GM stated Chief Clinical Officer educated her and DON on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 Level of Harm - Immediate with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief jeopardy to resident health or Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of safety [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior Residents Affected - Few to start of shift. DON stated daily and random audits will continue to assure compliance.

The GM was notified on 07/19/2024 at 05:27 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 676440