Health inspection·December 7, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/7/2023 at 1:46 PM with LVN B revealed that the controlled meds boxes on the medication carts are supposed to be audited and signed by the oncoming and off-going nurse/medication aide at every shift change. She also stated that this is facility policy. When asked if there were (3) .5mg Lorazepam that were in the drawer and on the controlled meds count for Resident #1, she confirmed there were. She stated they counted them in the shift change controlled meds count. When asked if they were supposed to be in the drawer, she stated, No. She went on to explain that the Lorazepam had been discontinued, but not taken to the DON. Review of facility's current Medication Administration: Controlled Drugs Record Keeping-SNF policy, dated February 2021, reflected: .3. The nurse receiving them will inventory and document receipt .4. Controlled drugs must be placed under lock and key immediately after they have been inventoried and the form for each medication has been signed and received. Review of facility's current Narcotic Count policy, dated February 2021, reflected: .1 At end of every shift .between oncoming and off-going staff . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675238 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 675238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Terrace 1600 Texas St Fort Worth, TX 76102 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to secure all controlled medications. LVN A failed to secure controlled medication behind a double lock by placing it in an unsecured cabinet in the medication room. This failure placed residents at risk of their controlled medications being misappropriated and thereby worsening their medical condition. Findings included: Record review of Resident #2's care plan, dated 11/21/23, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of hip replacement. Record review of Resident #2's annual MDS, dated [DATE], revealed the resident was cognitively intact with a BIMS score of 15. Her Functional Status indicated she required assistance with all her ADLs. Interview on 12/07/23 at 8:55 AM with DON revealed the resident was admitted on [DATE] by LVN B. The DON stated Resident #2 came from home with bag of medications all inside their bottles. The DON said that LVN B told Resident #2 that she couldn't keep the medications in her room. So LVN B counted the medications in each bottle, wrote the number of each one on the bottle, and then placed them bag in the sack. The DON stated LVN B did not create a count sheet for the Oxycodone (controlled medication). LVN B then locked the bag of medications in the controlled medications box on the medication cart. The DON revealed Resident #2 told LVN B that her family was coming that evening, and she would pick up the sack of medications at that time. However, Resident #2's never arrived that evening. The DON revealed on 10/30/23 LVN A removed the bag of medications from the locked box on the cart and placed them in an unlocked cabinet in the medication room. On 11/1/2023, Resident #2's asked for Resident #2's meds. LVN A went to retrieve the sack of medications, and it was not in the cabinet. The bag of missing medications was never located by the facility. The DON stated their consultant Pharmacist is involved. The Pharmacist said to reconcile and do a controlled meds dispense report which the DON completed. The DON stated the facility policy states that if a resident brings medications from home, the family should take the medications back home. Policy, per DON, also stated that if family doesn't take medications back home immediately, the medications are to be destroyed. The DON revealed home medications that were controlled medications were supposed to be counted and documented on the controlled medications sheets. The oncoming nurse/MA counts the controlled medications with off-going nurse/MA and they each sign the narc sheet. The DON revealed that LVN A did not follow this policy, which could possibly have led to the missing controlled medications. The DON stated there wasn't a negative impact to the resident. However, she stated that the facility did owe Resident #2 re-imbursement for the missing medication. The DON stated that Resident #2 was updated on the process. Observation on 12/07/2023 at 9:55 AM revealed medications for destruction are kept in the DON's office. They were observed to be under two locks in DON's office. The discontinued drugs log showed they were destroyed monthly when the pharmacist comes with the DON and pharmacist. They were last destroyed on 11/13/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675238 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 675238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Terrace 1600 Texas St Fort Worth, TX 76102 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/7/2023 at 10:43 AM revealed LVN A said she saw a bag of medications in her medication cart (not in the locked compartment). LVN stated that on 10/30/2023 she took the bag of medications (without looking inside the bag) and put the bag in the medication room in an unlocked cabinet. LVN A stated that the following day the family arrived to pick up the medications. LVN A went to retrieve the medications, and they were not in the cabinet. She stated she saw the bag of medications only once. She also revealed she should have looked in the bag. LVN A stated that if she would have opened the bag, she would have seen the controlled medication. Then she would ask another nurse to count and put them on the controlled medications sheet and reported it to the DON per policy. After this occurrence she was in-serviced. Since she has been here has been in-serviced on controlled medications twice. LVN A stated controlled medications should be stored in the medication cart in the lock box. LVN A said controlled medications should be always under two locks. She confirmed the bag of medications was placed in the locked medication room in an unlocked cabinet. She revealed only the MA's and nurses have access to the med room. Interview on 12/07/23 at 3:48 PM with LVN B revealed she admitted Resident #2 and completed the assessments on 10/27/23. LVN B stated that Resident #2 had brought a sack of her medications from home. LVN B stated that the sack of medications included: Over the counter medications, vitamins, and a 30-day supply of Oxycodone. Resident #2 said she would have her family come and pick up her sack of medications and take them back to her home. LVN B then called Resident #2's family and requested that she pick up Resident #2's medications The family member said that she would come that night to see the resident and pick up the medications. LVN B stated she then counted the Oxycodone and put the number of the pills in the bottle on the bottle along with each of the other bottles of medications accordingly. LVN B stated she then put the bag of medications in the lock box on the cart. LVN B revealed she should have made a count sheet for the Oxycodone because it was a narcotic. She stated she did not make a count sheet because she thought was going to pick up the medications that evening. She also stated she knew the resident would not be using the Oxycodone brought from home because the facility would provide any medications that were needed. LVN B then stated that was the last time she saw the sack of medications. LVN B stated there was a risk of misappropriation to the resident because it was not counted. And it was taken from the resident ultimately. LVN B stated it was her responsibility to place the controlled medication on the count sheet. LVN B stated the facility policy says to keep track of the meds. LVN B stated she did not think that anybody would steal it. She thought that a family member would come and take it home that evening and that the medications would not be kept in house. Review of facility's current Narcotic Count, Conducting policy, dated April 2022, reflected: .2.c .narcotics are to remain in the narcotics/bin drawer and counted during each count until they are appropriately destroyed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675238 If continuation sheet Page 4 of 4