Health inspection·February 8, 2024

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 4 of 4 reviewed for resident council. Residents Affected - Some The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Interview on 02/07/24 at 1:56 PM with the Activity Director revealed the resident council meeting would be held in the bird room which is the living/lounge room. She stated it was the best place with the most privacy. She stated she would keep a watch on the hall to make sure staff were aware of the meeting. Observation and interview on 02/07/24 beginning at 2:00 PM, during a confidential resident group meeting with four residents, revealed the meeting was held in the living/lounge room. There were no doors to close off the room. A sign was posted to indicate that a confidential meeting was being held. However, multiple staff and visitors walked through the hall to get to another hall and entering/exiting the elevators located across the living/lounge room. Also, the nurses' station was located next to the lounge room. During the confidential group meeting, three residents revealed the meeting was held each month in the dining area. While the meeting was being held, a confidential resident proceeded to state No privacy here while staff were exiting the elevator. The residents stated they were used to having staff around during their resident council meetings. Interview on 02/08/24 at 12:07 PM with the Activity Director revealed resident council meetings were held in the dining room area or at times in the living/lounge room. She stated after they completed an activity she would conduct a resident council meeting. She stated she would get more participation when residents were in the dining room. She stated normally four to five residents attended the resident council meetings monthly. She stated the facility did not have a private room area. However, since the census lowered in the last three weeks, they had rooms available. The Activity Director stated all the residents who participated in the resident council meetings monthly felt comfortable talking and there were no potential risks. Interview on 02/08/24 at 1:45 PM with the Administrator revealed the resident council meetings were always held in the dining room or in the bird room living/lounge room. She stated her expectations were for residents to be comfortable during meetings and if they wanted the meeting to be held in the dining room it should be respected. She stated she was not aware that the resident council Page 1 of 4 675238 675238 02/08/2024 Trinity Terrace 1600 Texas St Fort Worth, TX 76102

F 0565 meetings needed to be in a private area. She stated it had never been brought up to her attention. Level of Harm - Minimal harm or potential for actual harm Record review of the resident council minutes for October 2023 through January 2024 revealed no requests for a private area. Residents Affected - Some Record review of the facility's Resident Council Meetings policy, revised August 2013, revealed in part the following: It is the policy of the Company, when a resident(s) wish to organize a group meet, the facility will allow them to do so without interference. 1. The facility will provide the group with a private place to meeting 675238 Page 2 of 4 675238 02/08/2024 Trinity Terrace 1600 Texas St Fort Worth, TX 76102

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 observation and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all biologicals, to meet the needs of each resident for 2 of 4 glucose test strips reviewed for pharmacy services. Staff failed to remove expired glucose test strips, used to check residents' blood glucose levels, from the nurse medication cart. This failure could place the rresidents at risk of inaccurate blood testing results. Findings included: Observation on [DATE] at 10:00 AM of Nurse Medication cart revealed two vials of glucose monitoring strips had expired on [DATE]. The strips had been marked with an opening date of [DATE], which was two days after they had expired. Interview on [DATE] at 10:05 AM, LVN A stated she had not checked the glucometer strips recently because none of the residents on her hall required finger stick glucose monitoring. LVN A stated the nurse that opened the new vials should have checked for their expiration date. A new vial is marked with the opening date because they are only good for 30 days after they have been opened. LVN A stated using expired test strips could lead to an erroneous reading from the glucose monitor. Interview on [DATE] at 11:00 AM, the DON stated her expectation was for the nurses not to place expired test strips, or anything expired, on their carts. The test strips were checked weekly for acuracy when the glucose meter was checked for accuracy. 675238 Page 3 of 4 675238 02/08/2024 Trinity Terrace 1600 Texas St Fort Worth, TX 76102

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 (Medication Aide Cart) of 6 carts reviewed for pharmacy services. The facility failed to ensure MA-B secured her medication cart before walking away from it. This failure could allow residents to access medications not prescribed to them. Findings included: Observation on 02/08/24 at 10:30 AM revealed the medication aide's cart for the [NAME] Hall was unsecured. All of the drawers were able to be opened without the use of a key. Drawers contained both over the counter medications as well as prescribed medications. Interview on 02/08/24 at 10:35 AM, MA B stated she secured her cart before walking away, but she might not have pushed the button all the way in. MA B stated they had a problem a couple of weeks ago of carts not locking but she thought they had been repaired. She stated the risk of the cart being left unsecured was a resident getting a medication not prescribed for them. Interview on 02/08/24 at 11:10 AM, the DON stated the pharmacy company sent a tech out the previous week to work on two carts that were not securing properly. The DON stated she thought MA B's cart was one of the carts that was looked at. The DON stated the risk of a cart being left unsecured was a resident getting medications not prescribed for them and possibly having side effects that could be life threatening. Review of the facility's Medication Administration policy, dated February 2024, reflected: .5. Controlled drugs must be placed under lock and key immediately after they have been inventoried . 675238 Page 4 of 4