Health inspection·February 17, 2023

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MDS Nurse said she did not complete the PASRR I form. The MDS Nurse said she forwarded the forms that had been provided to her to the state for review . The MDS Nurse said she did not believe Resident #2's diagnoses of schizophrenia would have been approved for a PASRR II review due to his primary diagnosis of Parkinson's Disease. The MDS Nurse said she did not believe there would be any change to the outcome for Resident #2 despite an incorrect PASRR I review . The MDS Nurse reviewed Resident #2's admission Form, which included a diagnosis of schizophrenia with the diagnosis date of 6/27/2022. The MDS Nurse reviewed the PASRR I, also dated 6/27/2022. The MDS Nurse said the PASRR I form she sent to the state for review was incorrect and should have indicated Resident #2 had mental illness. The MDS Nurse said she was unsure if the agency that evaluated the PASRR would evaluate a form with no known mental illness, intellectual disability, or developmental delay . The MDS Nurse said the agency would call her if they determined the form was incorrect. The MDS Nurse said she relied on the PASRR I form completed prior to the residents' arrival at the facility and did not review it prior to sending it to the agency reviewing the PASRR I form. Observation and interview on 02/16/23 at 12:33 PM with the Admin , she said the PASRR was used to identify residents with mental illness prior to a resident's placement in a nursing facility, and ensure the placement was the most appropriate for that resident. The Admin said the PASRR may preclude a resident from long-term care due to the resident's behaviors and mental illness. The Admin said if a resident with mental illness was placed in a nursing facility the resident's doctor should ensure he/she did not become a danger to him/herself or others. The Admin stated the facility was required to have a PASRR I review prior to placement. The Admin said if the PASRR I was positive the state authorized agency should review the resident and determine if he/she was a candidate for a PASRR II screen and possible further services. The Admin said the facility's MDS Nurse should review the PASRR I that was provided to the facility prior to placement for accuracy. The Admin said the MDS Nurse should have a collaborative engagement with the individual who completed the PASRR I. The Admin said for a resident coming from a home setting whose PASRR I was not completed by a trained professional, the MDS Nurse should review the form with more scrutiny. The Admin reviewed Resident #2's PASRR I and admission form dated 6/27/2022 and said the PASRR I was incorrect because it noted no mental illness. The Admin said the resident was diagnosed with schizophrenia prior to placement and prior to the PASRR I. The Admin said the MDS Nurse should have reviewed the PASRR I form and noted it was incorrect prior to forwarding the form to the state authorized agency for review. The Admin said if a resident did not receive the correct PASRR review he/she may not receive the correct services and/or could have an interruption in services. Resident #8 Record review of Resident #8's face sheet, dated 02/14/23, indicated Resident #8 was [AGE] year-old male who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included unspecified dementia without behavioral or psychotic disturbance, Parkinson's disease, major depressive disorder, recurrent severe without psychotic feature, vascular dementia with behavioral disturbances, psychotic disorder with delusions due to known physiological condition, Anxiety disorder due to known physiological condition. Record review of Resident #8's PASRR 1, dated 03/08/19 , revealed Section C had questions for evidence of mental illness, intellectual disability or developmental disability marked No. Record review of Resident #8's 5-day MDS assessment, dated 12/07/22, indicated section I Psychiatric/Mood Disorder had Anxiety Disorder, Depression, and Psychotic disorder checked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 2 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/15/23 at 1:56 PM with MDS nurse, she said she received a PASRR Level 1 screen from the hospital for resident #8 and said that it was already marked with No . She said she sent it to the state as it was. She said if she did re-evaluated the form and checked yes, they (hospital and state) would call her back to question her about it. She stated the form was not correct . During an interview on 02/16/23 at 12:45 PM with Admin, she said she has worked at the facility for 3 weeks. She said PASRR was to identify if a resident had mental or intellectual disability such as bipolar or schizophrenia and if positive, they were transferred to the mental health professionals to determine if they qualified for certain resources and had the appropriate health care professionals to follow the residents for care needed. She said the MDS nurse was responsible for reviewing the PASRR to determine if it was filled out correctly. The Admin stated upon review of Resident #8's PASARR and diagnosis that the PASRR Level 1 was not filled out correctly. She said if the PASRR was not filled out correctly it could cause the resident not to get services needed or services could be interrupted . Record review of the facility's Policy and Procedure for PASRR Level I/PASRR Compliance, dated 6/27/2014, revealed The facility will ensure compliance with all Phase I and II guidelines of the PASRR process for Long Term Care. The policy listed the MDS coordinator and marketing/admissions team members as responsible for adherence to the policy and procedure. The procedures section of the document reported If a person is coming from a home or community setting, the family must complete the PASRR Level 1 form. The facility may assist in this process . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 3 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 10 residents (Resident #5, Resident #61, and Resident # 67) reviewed for ADLs. Residents Affected - Some The facility failed to ensure Residents #61, #5 and #67 received their scheduled showers. This failure could place residents at risk for not receiving care and services to meet their needs and ADL decline. Findings include: Resident #61 Record review of Resident #61's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #61 had diagnoses which included Cerebral Infraction, Human Immunodeficiency Virus (HIV) Disease, Hypertension, Schizoaffective Disorder, Major Depressive Disorder, and Bipolar Disorder. Record Review of Resident #61's Skin Monitoring: Comprehensive CNA Shower Review indicated Resident #61 did not receive showers on 01/02/2023, 01/04/2023, 01/06/2023, 01/11/2023. 01/16/2023, 01/18/2023, 01/25/2023, 01/30/2023, 02/03/2023, 02/08/2023, 02/10/2023. There was no documentation that the resident refused a shower for the month of January or February of 2023. Interview with Resident #61 on 02/14/2023 at 9:05AM, she stated she had been at the facility since July 2022. Resident #61 stated she was able to self-transfer but reported she required assistance with showering. She stated there was only one shower technician that assisted with showers. Resident #61 stated she was supposed to receive showers on Mondays, Wednesdays, and Fridays but she would sometimes go weeks without showers. She stated she spoke with the shower technician in the past regarding her concerns and was informed the shower schedule was full so she could not get to her. Resident #5 Record review of Resident #5's face sheet, dated 2/25/2023, revealed a [AGE] year-old female who had diagnoses including spastic hemiplegia affecting left dominant side (hemiplegia is a type of unilateral cerebral palsy that causes paralysis on only one side of the body), weakness, age related physical disability, lack of coordination, muscle wasting and atrophy multiple sites, dementia, need for assistance with personal care, TIA (a brief stroke-like attack), and cerebral infarction (a stroke). Record review of Resident #5's undated care plan revealed she required assistance with mobility, dressing, eating, toileting, personal hygiene, oral care, bathing, etc . as needed. Her care plan required her to have one staff assist with dressing and hygiene. Resident #5's care plan noted a focus related to potential for self-care deficit and decline due to stroke or TIA , with a goal for her to participate in her highest level of ADL's. The care plan required staff to allow Resident #5 time to complete self-care, encourage her to participate in ADL care, provide adequate rest periods between self-care activities, and provide assistance with mobility, dressing, eating, toileting, personal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 4 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hygiene, oral care, and bathing as needed. Resident #5's care plan also documented a focus related to skin breakdown. The focus on skin breakdown required staff to assist Resident #5 with bathing three times weekly. Record review of Resident #5's Quarterly MDS , dated 1/9/2023, revealed a BIMS score of 11 which indicated minimal cognitive delay or impairment. The MDS noted Resident #5 required extensive assistance with personal hygiene. She was totally dependent on staff for assistance with bed mobility, transfer, locomotion, dressing, and toilet use. She required one staff to assist with all of those tasks. The MDS further noted she required substantial/maximal assistance with showering and bathing. Record review of January and February's shower reports for Resident #5 revealed no showers were documented between 1/13 and 1/20, 1/27 and 2/3/20, and 2/3 and 2/8/2023 . Resident # 5 was scheduled to be showered on 1/16, 1/18, 1/30, 2/1, and 2/6/2023. Interview on 02/14/2023 at 10:16 AM, Resident #5 said she had to Resident #5 said she was not bathed routinely. Resident # 5 said she wanted to be bathed routinely but she was not. Resident #67 Record review of Resident #67's face sheet dated 2/15/2023 revealed a [AGE] year old female who had diagnoses which included cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), and unspecified pain . Record review of Resident #67's undated care plan revealed a focus related to an ADL self-care performance deficit decline disease, cerebral palsy, with a goal of improved level of functioning and ADL. The care plan revealed she required physical therapy and occupational therapy per doctor's orders, two-person assistance with transfers and bed mobility, one person assistance with bathing, person hygiene, dressing and eating to meet those goals. Record review of Resident #67's 12/6/2022 quarterly MDS revealed she had a BIMS score of 11, which indicated minimal cognitive delay or impairment. Resident #67's MDS noted she required extensive assistance of two staff with locomotion, dressing, and toilet use. She required limited assistance of one staff with bed mobility, transfers, personal hygiene and during the bathing process. She required physical help in bathing, and she required one person to assist during the bathing process. Record review of January and February's shower reports for Resident #67 revealed no showers were documented between 1/13 and 1/20, 1/25 and 2/2/20, 2/3 and 2/8/20, and 2/8 and 2/13/2023. Resident # 5 was scheduled to be showered on 1/16, 1/18, 1/27, 1/30, 2/1, and 2/6/2023. Interview on 02/14/2023 at 10:16 AM with Resident #67. She said she did not enjoy living at the facility. She said the staff did not change the residents timely, the food was not good, and bathing did not occur according to the schedule, and she did not get enough showers. Interview on 02/16/23 at 10:03 AM with LVN A, she said the level of ADL care provided was dependent on the residents' abilities. LVN A said ADL care included incontinence care. LVN A said the number of staff needed to assist a resident with his/her ADL care was dependent on the resident's weight and care needs. LVN A said ADL care included everything the resident could not do for him/herself which included, but not limited to, incontinence, feedings, oral care, hygiene, answering call lights, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 5 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and toileting. LVN A said the Certified Nursing Assistants (CNA's) were primarily responsible for providing ADL care. LVN A said the nurses assisted and supervised the CNA's in ADL care. LVN A said if staff did not provide incontinence care that could lead to infection or the resident being dirty. LVN A said a lack of ADL care could also lead to skin breakdown and/or emotional distress. Interview on 02/16/23 at 10:11 AM with CNA A she said ADL care included ensuring the residents were clean. CNA A said when she first started her shift she would assist with ADL's and passing food. CNA A said after breakfast she would assist residents getting up for the day, prepared for showers, and other activities. CNA A said ADL care included any activity a resident could not do for him/herself. CNA A said ADL care included showering, feeding, incontinence care, and hygiene care. CNA A said she was provided in-service training by the facility on ADL care. CNA A said if ADL care was not provided appropriately a resident could go downhill and the resident's care would suffer . Interview on 02/16/23 at 2:21 PM with the Shower Technician (ST ), she said she had been employed by the facility for a little over a year. The ST said she worked on an as needed basis but worked Monday through Friday 8:00 AM to 3:30 PM. The ST said if a resident refused a shower , she informed the resident's nurse. The ST said in the past she would document the refusals on a shower sheet, but she was informed not to do so by the Wound Tech Nurse. The ST said the nursing staff would try to convince a resident who refused a shower to shower, but if the resident continued to refuse the nurse would call the resident's family. The ST said the family may convince the resident to shower. The ST said she was responsible for showering all residents in the facility, but it was impossible to do so. The ST said she had thirty-four residents on Mondays, Wednesdays, and Fridays, and thirty-four on Tuesdays, and Thursdays . The ST said she could not get to all the residents timely due to the number of residents and her being the only shower tech. The ST said she would shower a resident on a Wednesday or Friday if she could not shower a resident on a Monday. Interview on 02/16/23 at 2:21 PM, the ST said she was instructed to notify the nurses of residents who were not showered and the 2:00 PM to 10:00 PM staff would shower those residents. The ST said she brought the shower sheets to the evening nurses for residents who she did not shower. The ST said showers were documented on shower sheets. The ST said bed baths would be documented on shower sheets if she was aware of them, but if she was not informed the bed baths may not be documented . The ST said she completed as many showers as she could but was unable to complete all the showers scheduled. Interview on 02/16/23 at 2:21 PM, the ST said she bathed Resident # 5 routinely, but Resident #5 was aware of the facility's short staff and was understanding if the ST could not bathe Resident # 5. The ST said Resident # 67 showered when she was able to but understood she could not shower every time she was scheduled because of the short staffing and was accepting of that. Interview on 02/16/23 at 3:27 PM, CNA B said she worked the evening shift at the facility. CNA B said she had been employed by the facility for three years. CNA B said during the evenings the CNA's ADL care consisted of assisting residents with feeding, incontinent care, preparing for bed, and hygiene. CNA B said evening CNA's did not bathe residents . Interview on 02/16/23 at 3:31 with PM, LVN B said she was a nurse on the evening shift. LVN B said the facility typically showered residents during the morning shift. LVN B said occasionally she would be provided the name of a resident who refused to shower during the day shift by day shift personnel. LVN B said the evening shift staff would try to bathe that resident during the evening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 6 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LVN B said this was not common. LVN B said the evening shift CNA's did not typically shower residents at night but would occasionally. Record review of the facility's Quality of Live: Activities of Daily Living (ADL's)/Maintain Abilities policy, dated 11/28/2017, read in part . To appropriately address resident and facility practices that would affect the resident's ability to attain and maintain his/her highest practicable well-being .The facility must provide the necessary care and services, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living . The facility must provide care and services, in accordance with the previous paragraph, for the following activities of daily living: .1. Hygiene-Bathing Record review of the facility's Quality of Life: ADL Care Provided for Dependent Residents policy, dated 11/28/2017, read in part . to appropriately address resident and facility practices that would affect the resident's ability to attain and maintain his/her highest practicable well-being . A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 7 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding, which included but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1 of 1 resident (Resident #69) reviewed for gastrostomy tube management. LVN A failed to appropriately check the placement of Resident #67's G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) by pushing by force 5 ml of water instead of air into the resident's G-tube and failing to check for residual. This failure could place residents at risk for adverse reactions, inadequate therapy, and a decreased quality of life. Finding include: Record review of Resident #69's face sheet, dated 02/15/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, GI hemorrhage (bleed), dysphagia (difficulty swallowing) and gastrostomy status. Record review of Resident #69's MDS, dated [DATE], revealed the resident had moderately impaired cognition as indicated by a BIMS score of 10 out of 15, required total dependence for most ADLs and was always incontinent of both bladder and bowel. Record review of Resident #69's, undated, Care Plan revealed focus- require tube feeding as ordered r/t moderate protein calorie malnutrition; interventions- provide tube feeding as ordered. Record review of Resident #69's Physician's Orders, dated 01/11/23, revealed Doxazosin 1 mg - give 2 tablets via g-tube one time daily. Record review of Resident #69's Physician's Orders, dated 01/12/23, revealed Ecotrin Low Strength Tablet Delated Release 81 mg (Aspirin)- give 1 tablet enterally (through the intestine) one time a day for pain. An observation on 02/15/23 at 08:12 AM revealed, LVN A prepared medication for administration to Resident #69 via g-tube. She retrieved 1 tablet of enteric coated 81 mg aspirin and 2 mg of Doxazosin, crushed them individually and returned them into separate medication cups. LVN A entered into Resident #69's room, dissolved each medication in 5 ml of water and then attempted to check for placement. LVN A withdrew 5 ml of water in a syringe, attached it to Resident #69's g-tube and injected it into the tubing while listening to the resident's abdomen with her stethoscope. The water LVN A injected into Resident #69's g-tube was observed to forcefully squirt out of the resident's tube. Once completed, LVN A flushed Resident #69's G-tube with 30 ml of water by gravity and then administered the dissolved Aspirin and Doxazosin with a 30 ml flush before and after the medication. LVN A did not check for residual prior to beginning her flush and medication administration. In an interview on 02/15/23 at 12:57 PM, LVN A said prior to administering medication via G-tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 8 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses were expected to check for placement of the resident's G-tube by injecting water into the tubing while auscultation (listening for gurgling noises in the stomach) and checking for residual. LVN A said it did not make a difference if air or water was used to check for placement and she forgot to check for residual. She said failure to confirm placement of a resident's G-tube could place residents at risk for damage to the tubing or injected medications/food leaking into areas outside of the stomach. LVN A said failure to check for residual could result in residents being overfed and experiencing stomach pain. In an interview on 02/15/23 at 01:30 PM, the DON said prior to administering medication via G-tube nurses must check for placement via auscultation by injecting air into the tube and then checking for residual. She said air must be used instead of water because stomach sounds could not be heard if water was used and pushing water forcefully through a syringe could damage the tubing. The DON said failure to check for residual and confirm placement of the G-tube in the stomach could place residents at risk for having the injected food/medication leak into areas outside of the stomach. Record review of LVN A's medication administration competency assessment, dated 02/07/23, revealed proper crushing technique, non-crushable meds have MD order. 'Do not Crush' information is available. The assessment did not cover administration of medication via g-tube. Record review of the facility policy titled Medication Administration Per Enteral/Gastric Tube, effective 01/01/2010, revealed .4-check tube for residual and proper placement. The document did not provide specific details on how to check placement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 9 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 - Few 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, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #69) reviewed for pharmacy services. The facility failed to administer the correct medication to Resident #69 by administering Pantoprazole instead of Lansoprazole as ordered by the MD for the treatment of the resident's GERD. This failure could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings include: Record review of Resident #69's face sheet, dated 02/15/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, GI hemorrhage (bleed), dysphagia (difficulty swallowing) and gastrostomy status. Record review of Resident #69's MDS, dated [DATE], revealed the resident had moderately impaired cognition as indicated by a BIMS score of 10 out of 15, required total dependence for most ADLs and was always incontinent of both bladder and bowel. Record review of Resident #69's, undated, Care Plan revealed focus- require tube feeding as ordered r/t moderate protein calorie malnutrition; interventions- provide tube feeding as ordered. Record review of Resident #69's Physician's Orders, dated 01/13/23, revealed Lansoprazole oral suspension 3 mg/ml. Give 10 ml via g-tube every 12 hours related to GERD. Record review of Pharmacist Recommendation, dated 01/31/23, revealed: the pharmacist notified the physician Resident #69 was prescribed both Pantoprazole and Lansoprazole, which was a duplication. The pharmacist recommended Resident #69 only received one of the medications, and Pantoprazole was discontinued. Record review of Resident #69's February MAR revealed, Lansoprazole oral suspension 3 mg/ml. Give 10 ml via g-tube every 12 hours related to GERD. The medication was signed as administered on: - 02/01/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/02/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/03/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/04/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/05/23 doses scheduled for 9:00 AM and 9:00 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 10 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 - 02/06/23 doses scheduled for 9:00 AM and 9:00 PM. Level of Harm - Minimal harm or potential for actual harm - 02/07/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/08/23 doses scheduled for 9:00 AM and 9:00 PM. Residents Affected - Few - 02/09/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/10/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/11/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/12/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/13/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/14/23 doses scheduled for 9:00 AM and 9:00 PM. - 02/15/23 doses scheduled for 9:00 AM. Record review of Resident #69's Pharmacy Record from 12/01/22 to 02/27/23 revealed, Pantoprazole 2 mg/ml was filled on 12/23/22 and 01/12/23. There is no documentation of the pharmacy filling Lansoprazole for Resident #69. An observation and interview on 02/15/23 at 08:12 AM revealed, LVN A prepared medication for administration to Resident #69. She retrieved 1 tablet of Aspirin 81 mg and 1 tablet of Doxazosin 2mg and a bottle of Pantoprazole 2mg/ml liquid solution from the medication cart. The pharmacy label read take 20 ml via tube every 12 hours. The State Surveyor observed the MAR, LVN A referred to stated Lansoprazole 3mg/ml and asked LVN A if this was the medication being administered to Resident #69 for treatment of his GERD. LVN A said she administered pantoprazole to Resident #69 from the bottle on multiple occasions and said pantoprazole and lansoprazole were interchangeable and were just different brand names of the same medication. LVN A said she would not administer the medication to Resident #69 and she would verify what to do with her DON. The bottle of Pantoprazole had a labeled fill date of 12/23/23 and 1/3rd of the volume of the bottle remained. In an interview on 02/15/23 at 12:57 PM, LVN A said prior to administering medication nurses should first identify their selves to the resident, inform the resident medication would be administered verifying the resident against the MAR, retrieve the medication while verifying the medication to be administered against the MAR and then administering the medications. She said after talking to the DON she stated Pantoprazole and Lansoprazole were not the same medication and the DON had received a new prescription for Pantoprazole from Resident #69's physician. In an interview on 02/15/23 at 01:30 PM, the DON said prior to medication administration nursing staff were expected to verify the patient as well as the medication to be administered against the MAR. She said Lansoprazole and Pantoprazole were not interchangeable and were in fact 2 different medications used to treat GERD. The DON said she did not know how the error with the Lansoprazole occurred and the facility received Pantoprazole from the pharmacy not Lansoprazole. The DON said after contacting the physician, Resident #69's prescription was changed to Pantoprazole by the MD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 11 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 - Few In an interview on 02/15/23 at 2:31 PM, the Pharmacy Staff said the pharmacy had filled and delivered Pantoprazole 2 mg/ml on 12/23/22 and 01/12/23 to the facility. She said the pharmacy had never filled or delivered Lansoprazole solution to the facility for Resident #69. Record review of LVN A's medication administration competency assessment, dated 02/07/23, revealed 6correct medication verified by visual check of med, label and MAR. Record review of the facility policy titled Free of Medication Error Rate of 5% or Greater or Free of Significant Med Error, effective 11/28/17 revealed, the facility will follow physician orders and/or medication specific guidelines for medication administration to ensure the facility medication error rate is below 5% and facility residents are free from significant medication errors. Record review of the facility policy titled Oral (PO) Administration of Medication, effective 01/01/2010, revealed no instructions to verify medication to be administered against the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 12 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 18 percent based on 6 errors out of 32 opportunities, which involved 5 of 8 residents (Resident #6, Resident #45, Resident #65, Resident #69 and Resident #273) reviewed for medication errors. Residents Affected - Some - MA A failed to administer medication to Resident #6 as ordered by administering Lidocaine 4% instead of Lidocaine 5% as ordered by the MD. - RN A failed to administer medications to Resident #45 as ordered by administering Linzess ( medication to treat constipation) at 9 AM, regardless of food as ordered and 2 hours after the scheduled administration time. - MA A failed to administer the correct medication to Resident #65 by administering Metoprolol Succinate instead of Metoprolol Tartrate as ordered by the physician. - LVN A failed to administer medication to Resident #69 appropriately by cutting enteric coated Aspirin 81 mg, a medication that should not be cut. - MA A failed to administer Lactulose (medication to reduce ammonia levels in the blood) to Resident #273 as ordered by administering 20 ml instead of 30 ml. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings include: Resident #6 Record review of Resident #6's face sheet, dated 02/15/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: hypertension and acute pain due to trauma. Record review of Resident #6's MDS, dated [DATE], revealed impaired vision, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, required limited assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of Resident #6's, undated, Care Plan revealed Focus- pain related to fracture of left rib, trauma to left rib area; intervention- administer pain medication as per MD orders and note the effectiveness. Record review of Resident #6's Physician's Orders, dated 09/29/23 at 4:37 PM, revealed Lidoderm Patch (brand name product for Lidocaine 5%)- apply to back topically one time a day related to acute pain due to trauma. An observation and interview on 02/15/23 at 09:43 AM revealed, MA A prepared to administer medication to Resident #6. She retrieved a box of Lidocaine 4% patches, entered into Resident #6's room and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 13 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0759 Level of Harm - Minimal harm or potential for actual harm applied a single Lidocaine 4% patch to Resident #6's lower back. MA A said the prescription Lidoderm did not have a strength and all the facility had was Lidocaine 4% so that was what she administered to the resident. MA A did not know the product Lidoderm was a specific strength. Resident #45 Residents Affected - Some Record review of Resident #45's face sheet, dated 02/15/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: dysphagia (difficulty swallowing) hypertension and quadriplegia (paralysis of all four limbs). Record review of Resident #45's MDS, dated [DATE], revealed severely impaired cognition as indicated by a BIMS score of 00 out of 15, and required total dependence on most ADLs. Record review of Resident #45's, undated, Care Plan revealed focus- risk for impactions hemorrhoids and bowel obstructions r/t constipation; interventions- administer medications as ordered. Record review of Resident #45's Physician's Orders, dated 04/22/21, revealed, Linzess 72 mcg- give 1 capsule by mouth one time a day for constipation, give 30 minutes before breakfast. Linzess 72 mcg was scheduled for administration at 7:00 AM. An observation on 02/15/23 at 7:40 AM revealed, breakfast trays being delivered to the 100 hall in which Resident #45 resided in. An observation on 02/15/23 at 9:00 AM revealed, RN A prepared medication for administration to Resident #45. He retrieved 1 capsule of Linzess 72 mcg and 7 other solid medications, opened capsules and crushed all the pills mixing each individually in apple sauce. RN A entered into Resident #45's room and administered her medications mixed in applesauce individually. Resident #65 Record review of Resident #65's face sheet, dated 02/15/23, revealed an [AGE] year-old year old male who was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, anemia and constipation. Record review of Resident #65's MDS, dated [DATE], revealed use of corrective lenses, severely impaired cognition as indicated by a BIMS score of 07 out of 15, required extensive assistance with most ADLs and frequent incontinence of both bladder and bowel. Record review of Resident #65's, undated, Care Plan revealed, Focus- Resident has hypertension; interventions- give hypertensive medications as ordered, metoprolol. Record review of Resident #65's Physician's Order, dated 09/22/22, revealed Metoprolol Tartrate 25 mggive 1 tablet by mouth one time a day r/t hypertension. An observation on 02/15/23 at 08:35 AM revealed, MA A prepared medications for administration to Resident #65. She retrieved 1 tablet of Metoprolol Succinate 25 mg as well as 9 other medications and administered them to Resident #65. Resident #69 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 14 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #69's face sheet, dated 02/15/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes, GI hemorrhage (bleed), dysphagia (difficulty swallowing) and gastrostomy status. Record review of Resident #69's MDS, dated [DATE], revealed moderately impaired cognition as indicated by a BIMS score of 10 out of 15, required total dependence for most ADLs and was always incontinent of both bladder and bowel. Record review of Resident #69's, undated, Care Plan revealed focus- require tube feeding as ordered r/t moderate protein calorie malnutrition; interventions- provide tube feeding as ordered. Record review of Resident #69's admission ordered, dated 01/11/23, revealed Aspirin 81 mg daily via G-tube for pain. Record review of Resident #69's Physician's Orders revealed, dated 01/12/23, revealed Ecotrin Low Strength Tablet delayed Release 81 mg (Aspirin)- give 1 tablet enterally (by mouth) one time a day for pain. An observation on 02/15/23 at 08:12 AM revealed LVN A prepared medication for administration to Resident #69 via g-tube. She retrieved 1 tablet of enteric coated 81 mg aspirin and 2 mg of Doxazosin, crushed them individually and returned them into separate med cups. LVN A entered into Resident #69's room, dissolved each medication in 5 ml of water and then administered the medications after checking placement with a 30 ml water flush before and after the medications. In an interview on 02/15/23 at 12:57 PM, LVN A said enteric coated or extended release medications could not be crushed because crushing them would change how the medication was dispersed in the body. LVN A said the facility had chewable Aspirin 81 mg and she said she didn't notice the medication she crushed was enteric coated and she only followed the prescribers order. She said crushing enteric coated or extended release mediation placed residents at risk for not getting the strength of medication they were prescribed. Resident #273 Record review of Resident #273's face sheet, dated 02/15/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included hepatic encephalopathy (a loss of brain function when a damaged liver dose not remove toxins like ammonia from the blood). Record review of Resident #273's MDS, dated [DATE], revealed impaired vision, moderately impaired cognition as indicated by a BIMS score of 09 out of 15, worsening of behavioral symptoms, required total dependence on all ADLs and was always incontinent of both bladder and bowel. Record review of Resident #273's, undated, care plan revealed focus- liver disease r/t increased ammonia level, interventions- lactulose as ordered for increased ammonia level. Record review of Resident #273's Physician's Orders, dated 02/06/23, revealed Lactulose 10 gm/15 mlgive 30 ml by mouth three times a day. An observation and interview on 02/15/23 at 08:35 AM revealed, MA A prepared medication for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 15 of 16 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 675493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Park Care Center 8861 Fulton Street Houston, TX 77022 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #273. She poured out 20 ml of Lactulose and said she did not have enough to administer the dose since the physician's order required 30 ml so she had to check the medication room for more medication. MA A returned from the med room and administered the 20 ml of Lactulose to Resident #273 instead of 30 ml as ordered. MA A said she could not find additional Lactulose for Resident #273 in the med room so she administered the 20 ml because failure to administer any lactulose would leave the residents condition untreated. In an interview on 02/15/23 at 01:30 AM, the DON said prior to administering medication nursing staff were expected to verify the medication against the MAR and administer only per the physician's order. She said the medication administration window was +/- one hour of the scheduled time and medications should be administered in regard to meals as ordered by the physician. The DON said when medications that were ordered on an empty stomach or before meals were given with meals the medication might not be absorbed in the body correctly or have the same efficacy. She said enteric coated medications like Aspirin 81 mg EC should not be crushed because it would impact the dispersion of the drug within the body and Metoprolol Succinate and Metoprolol Tartrate were not interchangeable since Metoprolol Succinate was an extended release while Metoprolol Tartrate was an immediate release formula. She said failure to administer the correct formulation of Metoprolol could result in unpredictable drug release and the resident not receiving the therapeutic effect as ordered by their physician. The DON said she did not know the brand name Lidoderm was Lidocaine 5% but by administering Lidocaine 4% instead of 5% as ordered residents could be at risk for insufficient therapy and uncontrolled pain. She said the facility expectation was all medications were administered as ordered and failure to do so could place residents at risk for inadequate therapy. Record review of the Medication Administration Observation Report, dated 11/15/22, revealed 11-meds given AC, PC, w/meals, w/antacids admin correctly. All assessed competencies were met. Record review of LVN A's Medication Administration Observation Report, dated 02/07/23, revealed proper crushing technique, non-crushable meds have MD order. 'Do not Crush' information is available. The assessment did not cover administration of medication via g-tube. All assessed competencies were met. Record review of MA A's Medication Administration Observation Report dated 02/10/23, reveled, 6correction medication verified by visual check of med, label and MAR. 8- Liquid medication measured accurately, shaken and/or diluted when appropriate. All assessed competencies were met. Record review of the facility policy titled Free of Medication Error Rate of 5% or Greater or Free of Significant Med Error effective 11/28/17 revealed the facility will follow physician orders and/or medication specific guidelines for medication administration to ensure the facility medication error rate is below 5% and facility residents are free from significant medication errors. Record review of the facility policy titled Crushing Medications effective 01/01/10 revealed, 1- crushing medications is an acceptable practice unless giving the medications together is contraindicated or the medications are time-released, enteric coated, effervescent, sublingual or buccal tablets. Record review of the facility policy titled Oral (PO) Administration of Medication, effective 01/01/10, revealed, 4- If medication is liquid, pour correct amount directly into a graduated medication cup or measuring device provided with liquid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675493 If continuation sheet Page 16 of 16