Health inspection·July 9, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident's right to be free from abuse, neglect, misappropriation of resident property and exploitation for three of five residents (Resident #1, Resident #2, and Resident #3 ) reviewed for drug diversion. 1. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #1.2. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #2.3. The facility failed to ensure LVN A did not take 30 (thirty) Torsemide 100 mg tablets prescribed for Resident #3. These failures could place residents at risk of misappropriation, medication errors and compromised health conditions. Findings include: Record review of the facility's self-report intake, dated 5/5/2025, revealed the following: Narrative of The IncidentSame nurse entered orders for three different residents for the same medication, Torsemide. The medications were then discontinued after the pharmacy delivered the medications. Medications were signed in by same nurse and facility unable to locate three of the four medication cards that were delivered. The Medical Director and NP deny giving nurse orders for Torsemide on any of the identified residents.1. Record review of Resident #1's face sheet, dated 7/9/2025, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Her diagnoses included: Hypothyroidism (thyroid produces too much thyroid hormone), Hypertension (high blood pressure), Age-related decline (natural changed in thinking speed, memory and cognitive abilities that occur when people age, Cerebral Infarction. Record review of Resident #1's Quarterly MDS assessment, dated 6/26/2025, revealed she had a BIMS score of 3, which indicated severely impaired cognition. Record review of Resident #1's Care Plan, initiated 4/10/2025, revealed focus areas which included: I have a Vitamin/Mineral deficiency. Intervention listed as Administer medication as ordered by M.D Record review of Resident #1's Order Summary, dated 3/8/2025 at 12:40 AM, revealed an unauthorized order entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for fluid overload. A verbal order was entered in PCC by LVN-A on 3/8/2025 at 9:24 PM to discontinue the Torsemide 100mg. Record review of the Delivery Manifest Report Details, Manifest ID: M412308X0000638512, dated 3/8/2025, revealed LVN-A received sixty (60) Torsemide 100mg tablets order for Resident #1. 2. Record review of Resident #2's face sheet, dated 7/9/2025, revealed a [AGE] year-old female resident who was admitted to the facility on [DATE]. Her diagnoses included: Senile Degeneration of the Brain (cognitive decline), Major Depressive Disorder (persistent sadness and loss of interest in activities) and Hyperlipidemia (high cholesterol). Record review of Resident #2's Quarterly MDS assessment, dated 5/16/2025, revealed she had a BIMS score of 7, which indicated severely impaired cognition. Record review of Resident #2's Care Plan, initiated 5/4/2025, revealed focus areas which included: I have a Vitamin/Mineral deficiency. Intervention listed as Administer medication as ordered by M.D. Record review of Resident #2's Order Summary, dated 4/23/2025 at 9:16 PM, revealed an unauthorized verbal order was entered in Page 1 of 3 455515 455515 07/09/2025 Copperas Cove Nursing & Rehabilitation 607 W Ave B Copperas Cove, TX 76522

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for edema. A verbal order was entered in PCC by LVN-A on 4/23/2025 at 9:16 PM to discontinue the Torsemide 100mg. Record review of Delivery Manifest Report Details, Manifest ID: M412308X0000640574, dated 4/26/2025, revealed LVN-A received ten (10) Torsemide 100mg tablets order for Resident #2. Record review of Resident #2's Physician's Order, dated 4/29/2025 at 3:22 AM, revealed an unauthorized verbal order was entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for edema. A verbal order was entered in PCC by LVN-A on 4/29/2025 at 3:22 AM to discontinue the Torsemide 100mg. Record review of Resident #2's Physician's Order, dated 4/29/2025 at 5:03 PM, revealed an unauthorized phone order was entered in PCC by LVN-A to discontinue the Torsemide 100mg. Record review of Delivery Manifest Report Details, Manifest ID: M412308X0000640770, dated 5/1/2025, revealed LVN-A received thirty (30) Torsemide 100mg tablets order for Resident #2. 3. Record review of Resident #3's face sheet, dated 7/9/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: Type 2 Diabetes (body does not produce enough insulin), Hypertension (high blood pressure and Hyperlipidemia (high cholesterol). Record review of Resident #3's Quarterly MDS assessment, dated 5/16/2025, revealed she had a BIMS score of 7, which indicated severely impaired cognition. Record review of Resident #3's Order Summary, dated 5/2/2025 at 9:55 PM, revealed an unauthorized verbal order was entered in PCC by LVN-A for Torsemide Oral Tablet 100mg. Give (1) tablet by mouth two times a day for edema. A verbal order was entered in PCC by LVN-A on 5/3/2025 at 10:46 PM to discontinue the Torsemide 100mg. Record review of the Delivery Manifest Report Details, Manifest ID: M412308X0000640825, dated 5/3/2025 revealed LVN-A received thirty (30) Torsemide 100mg tablets order for Resident #3. During an interview on 7/9/2025 at 4:45 PM, the CMA employed with the facility for one-year, stated she was in-serviced on misappropriation within the last month. She said she would report misappropriation and/or drug diversions to the DON and ADM. She said she had not seen any medications that were not been locked in the medication cart or room.During an interview on 7/9/2025 at 5:10 PM, CNA employed at the facility for 18 months, stated she received monthly training on misappropriation and stated she would report to the charge nurse, DON, and ADM. She said she had not seen any medications that had not been locked in the medication cart or room. During an interview on 7/9/2025 at 5:25 PM, LVN-C employed at the facility for three-years, stated she received monthly in-services on misappropriation. She said if she had identified something was missing, she would have tried to locate it and then report to the DON if it could not be located. She said when medications were received from the pharmacy, the nurse was responsible to receive them, sort and verify all medications were accounted for and they were passed off to the CMAs to put them into the medication cart. She said nurses were only allowed to enter standing orders and should have obtained an approval from the nurse practitioner or medical director for all other medication orders. She said, It was illegal to enter medication orders if we did not have approval from the medical director. During an interview on 7/9/2025 at 5:40 PM, LVN-D employed at the facility for ten-years, stated when medications were delivered by the pharmacy, the nurse checked the medications against the inventory and then it was handed-off to the medication aide and placed on the medication cart. She said narcotics were placed in the locked narcotics box by the nurse. She said nurses were only allowed to enter standing orders into PCC. She identified potential harm as, We could kill someone. During an interview with the DON on 7/9/2025 at 6:00 PM, the DON employed at the facility for three-months, stated she had placed at the nurses' station a misappropriation in-service and staff were reviewing. She reviewed the process for receiving medications when the pharmacy delivered them. She said only nurses were approved to sign for the medications and the nurse was to ensure the medication count was 455515 Page 2 of 3 455515 07/09/2025 Copperas Cove Nursing & Rehabilitation 607 W Ave B Copperas Cove, TX 76522

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some correct. She said two signatures were required when narcotics were received. She said she ran a report from the pharmacy system and could see that LVN-A signed for the missing Torsemide, which required only one signature. She said all mediation orders were reviewed daily by the DON and ADON. Three of the four medication cards for Torsemide remained missing at the time of the interview. She said she spoke with LVN-A who admitted she entered the orders and discontinue orders into PCC to check the functionality of the system. She said LVN-A denied receiving the Torsemide from the pharmacy and she did not know the whereabouts of the medication. During an interview with the ADM on 7/9/2025 at 6:30 PM, the ADM employed at the facility for eighteen-months, stated when the pharmacy dropped of medications, the nurses were responsible to verify each medication that was delivered and sign for the medication. She said nurses were not allowed to enter medication orders without an order from the nurse practitioner or medical director. She identified harm as the resident could have been double-dosed, had an allergic reaction, potentially overdosed, and had drug to drug interactions. She said the DON and ADON were responsible to review the medication orders during the week and the RN Supervisor was responsible on the weekends. She said the process had been tightened up (improved) since the Torsemide drug diversion. An interview was attempted on 7/9/2025 with LVN-A and was unsuccessful. Interviews were attempted on 7/10/2025 and 7/14/2025 with the Medical Director and were unsuccessful. Record review of the facility's in-service titled, Discontinued Medications, 2001 MED-PASS Revised April 2007, reflected the following: Policy statement Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. Policy Interpretation and Implementation:1. A practitioner's order to discontinue a resident's medication must be documented in the resident's clinical record and on the medication administration record (MAR).2. The nurse receiving the order to discontinue a medication is responsible for recording the information (e.g., writing discontinued date, dating, and initialing MAR) and notifying the dispensing pharmacy of the discontinuation.3. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. 455515 Page 3 of 3