Inspection·October 13, 2022

F 0755 signed out 1 tablet on the Narcotic count log for their appropriate administration time. Level of Harm - Minimal harm or potential for actual harm Review of Resident #5's MAR dated September 1, 2022 - September 30, 2022, revealed that LVN A, LVN B, and LVN C did not document the administration of the 1 tablet they had documented on the Narcotic count sheet for dates 9/11/22, 9/19/22, and 9/29/22. Residents Affected - Some Review of Resident #5's MAR dated October 1, 2022 - October 31, 2022, revealed LVN D and LVN E did not document the administration of the 1 tablet they had documented as administered on the narcotic count sheet for Resident #5's Tylenol with Codeine #3. Observation and interview on 10/13/22 at 9:42 AM, during narcotic count verification of med cart belonging to LVN B revealed narcotic count sheet for Resident #5 showed a remaining count of 29 for her Tylenol with Codeine #3. The bubble pack for Resident #5's Tylenol with Codeine #3 revealed two separate bubble packs one bubble pack had 9 tablets remaining and the other bubble pack had 19 tablets remaining totaling a count of 28 tablets. The count on the narcotic count sheet should match the same number of remaining tablets in the bubble pack(s). LVN B verified the count was accurate in the bubble packs as being 28 remaining tablets. LVN B said he had not administered any of the medication from the bubble pack to Resident #5 during his shift on 10/13/22. LVN B stated that he counted all the narcotics in the med cart with LVN F at the beginning of his shift and believed the counts were accurate that what was documented on the narcotic count sheet was the same number of tablets remaining in the bubble packs. LVN B then said, well wait [LVN F] gave one of the pills on 10/12/22 and she didn't document it. Interview on 10/13/22 at 10:15 AM, the DON stated the medication carts should be checked once per week by the ADON to verify the narcotic counts are correct. She said the off going nurse and the oncoming nurse should have counted the narcotics together and both verified that the number of tablets remaining in the bubble packs matched the number that was documented as remaining on the narcotic count sheet. Interview on 10/13/22 at 10:42 AM, the ADON revealed the nurses on each med cart should count the narcotics and verify the count matched the narcotic count sheet at the beginning of their shift, during the med pass itself, when they went on break and came back from break. ADON said that she would pick a day of the week to audit the med carts, she said that when she completed her audit, she would verify the count on the narcotic count sheets to verify there were no omissions of signatures and the count was a running count. ADON stated that she runs a report of all controlled substances and then she compares that to the narcotic count sheets to verify the medication is still on the cart. She said she did not compare the bubble packs with the count sheets. Interview with DON on 10/13/22 at 11:26 AM, revealed she had determined that a medication was not documented as being given on Resident #5's narcotic count sheet. She said that LVN F had given one tablet on 10/12/22 during the night and did not sign the tablet off of the narcotic count sheet. The DON stated that LVN F was on her way to the facility to sign the pill off of the narcotic count sheet. Surveyor informed DON that there was more than just the one error on the narcotic count sheet for Resident #5's Tylenol with Codeine #3; that according to the MAR and the narcotic count sheet there was a discrepancy in the counts of the medication. The DON said she was investigating the incident and would take action as needed upon her investigation. Interview on 10/13/22 at 12:11 PM, LVN G stated the ADON did a cart audit on her med cart weekly but that the ADON mainly just looked at the narcotic count sheets and then looks at the MAR to make (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0755 sure there is still an active order for that narcotic. Level of Harm - Minimal harm or potential for actual harm Interview on 10/13/22 at 12:29 PM, Resident #5 stated she had a physician's order for Tylenol with codeine #3 in which she had received every time she had asked for it. Resident #5 said that she thought she could have the pain medication every six hours. Residents Affected - Some Interview on 10/13/22 at 1:45 PM, LVN F stated she had administered 1 tablet of Tylenol with codeine #3 to Resident #5 on 10/12/22 at 4:40 AM but did not sign the tablet off of the narcotic count sheet for that medication. LVN F stated that she did count the narcotics with LVN B at the end of her shift on 10/13/22 at 6:00 AM and she read the count off of the narcotic count sheets and LVN B confirmed the count in the bubble packs matched the number she read out loud. She said that she did not know there was a discrepancy in the counts until the DON had called her and asked her about the counts and what she had documented on the MAR. LVN F stated that she had administered 2 doses of Resident #5's Tylenol with codeine #3 on dates 10/7/22 at 4:20 AM and 10/12/22 at 4:40 AM and did not sign the tablets out on the narcotic count sheet, but did document the medication as given on the MAR. She said she thought she had forgotten to sign the tablets out on the narcotic count sheet. LVN F said that the oncoming nurse counts the bubble packs and the off going nurse reads the count remaining from the narcotic count sheet. She stated that she did not recall a time that the counts were not accurate. Interview on 10/13/22 at 2:23 PM, LVN B stated that he had signed out one of Resident #5's Tylenol with codeine #3 on the narcotic count sheet on 9/19/22 at 11:00 AM, and he did not document the medication as being given on the MAR for Resident #5. LVN B said he must have forgotten to document the med as given on the MAR due to being busy. LVN B said that he should document on the narcotic sheet as soon as he pops the tablet from the bubble pack and then after administration of the tablet, he should have documented the administration on Resident #5's MAR. LVN B said he had counted the med cart narcotics on 10/12/22 with LVN F who was the off going nurse and he said he did not note any discrepancies. LVN B said he then counted the narcotics with LVN E on 10/12/22 at 2:00 PM in which no discrepancies were noted during that count either. LVN B said that when he counted the narcotics, he usually would look at the bubble pack and make sure that the count in the bubble pack matched the count number on the narcotic count log. LVN B continued to say during his interview I don't know what happened. Interview on 10/13/22 at 2:49 PM, LVN E had documented on the narcotic count sheet that he had administered Tylenol with codeine #3 to Resident #5 on 10/7/22 at 9:00 PM but had not documented the administration on the MAR. LVN E stated that he had come onto shift on 10/12/22 at 2:00 PM and had counted the narcotics with LVN B. LVN E said that during the count of the narcotics LVN B read the number of tablets remaining from the narcotic count sheet and he reviewed the bubble packs to make sure the numbers were the same. He said he did not recall the number being different for Resident #5's Tylenol with codeine #3 during the count with LVN B. LVN E continued to say he didn't think the count was wrong but could not remember. He said that when he came on shift 10/13/22 he was told by LVN B that the count for Resident #5's Tylenol with codeine #3 was inaccurate. LVN E also stated that he was not allowed to administer medications to Resident #5 due to an allegation she had made a while back. He said that he would prepare her medications then give them to another nurse on the hall to administer for him. LVN E said he did recall signing out the narcotic on 10/6/22 at 9:25 PM and on 10/7/22 at 9:00 PM and he gave the tablets to another nurse (could not recall name) to administer to Resident #5. LVN E said he knew it was not ethical to sign out for a medication he did not administer, assumed that the nurse had forgotten to sign the med off on the MAR as she normally would. LVN E said he would sign the tablet off of the narcotic count sheet and the nurse that administered the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication would document the administration on the MAR. LVN E said he counted the med cart narcotics with LVN F on 10/12/22 at 10:00 PM and did not recall a discrepancy in the count on the narcotic count sheet compared to the bubble packs. Interview on 10/13/22 at 3:06 PM, with the DON stated she was aware of LVN E not administering the medications that he had prepared for Resident #5. She said it had to do with an allegation; so, he prepared the medications and another nurse in the facility would administer the medications. The DON said she was unsure who would do the documenting on the narcotic count sheet and the MAR for Resident #5. Interview with the DON on 10/13/22 at 4:05 PM, revealed she is not familiar with a reconciliation form used to reconcile MARS with narcotics and narcotic count sheets. The DON stated she had started in-servicing nursing staff on controlled substance administration and that the nurse must sign both the narcotic count sheet and the MAR during administration. DON stated that LVN E would not have Resident #5's medications on his med cart and that another nurse would be solely responsible for the complete administration of the medications to Resident #5. DON said that LVN F had came back to the facility and signed out the tablet that she had administered on 10/12/22 and that the DON and ADONs were investigating the reason for omissions on the narcotic count sheet compared to the MAR and the breakdown of what nurses did not verify narcotic counts correctly. Phone Interview on 10/13/22 at 5:15 PM with LVN A who stated he had administered Tylenol with codeine #3 to Resident #5. He stated that he would pull the bubble pack from the narcotic log drawer on the med cart. He would pop the one tablet then he would verify the count on the bubble pack matched the narcotic count sheet. LVN A said he would sign the one tablet out on the narcotic count sheet then he would administer the medication to Resident #5. He said that after he administered the medication, he would document the medication as being given on the MAR that corresponds to the resident and the medication. LVN A said he could not recall a time when he did not document the medication as being administered on the MAR but guessed it could have happened. He said he did not recall the narcotic count ever being wrong when he would count the cart at the beginning and end of his shift. Phone calls placed to LVN C on 10/13/22 at 2:36 PM and LVN D on 10/13/22 at 2:39 PM; no answer, left a voicemail for return call. Review of facility's policy dated 9/2018 and a revision date of 8/2020 titled Storage of Controlled Substances Revealed bullet point 4. A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, II, IV, and V medications, including those in the emergency supply. 5. Unless otherwise indicated in a facility policy and/or as required by state regulations, the following will be performed: a. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented. 6. Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately and/or in accordance with facility policy. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The Director of Nursing documents irreconcilable discrepancies per facility policy. a. The administrator, consultant pharmacist, and/or Director of nursing determine whether other actions are needed (e.g., notification of police or other enforcement personnel). b. The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all mediations ordered and the goal of therapy is met. 7. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and documented on a Control Count Sheet (or similar form) or in accordance with facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455592 If continuation sheet Page 4 of 4