Health inspection·April 19, 2023

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few RNs are responsible for changing the midline IV dressing weekly. LVN C said Resident #39's IV dressing needed to be changed because it had dried blood under it. She said nursing staff needed to be able to always assess the IV site, and Resident #39's site could not be assessed because of the dried, blood-stained gauze. She added a soiled dressing such as the one on Resident #39 could potentially cause an infection. LVN C said the site was to be assessed for signs of infection, which included redness, warmth, and drainage. Observation and interview on 04/18/23 at 12:00 p.m. with Regional Nurse at Resident #39's bedside. He said the midline IV catheter was inserted on 04/15/23 by an outside vendor, and the dressing site should have been dated and initialed at that time. He said the IV site should not have dried blood under the dressing, and the dressing should have been changed 24-48 hours after insertion, and it did not appear to have been changed per policy. Regional Nurse said midline IV sites should also have dressing changes when visibly soiled and PRN (as needed). He said the treatment nurse, who was an RN, was responsible for midline IV dressing changes. During an interview on 04/18/23 at 12:15 p.m., DON said her expectations were IV sites to be assessed and dressing changes performed per facility policy. She said Resident #39's midline IV site dressing should have been changed due to soiled dressing. She added this oversight could potentially lead to an infection of the site. 2. Record review of admission physician orders dated 04/10/23 indicated Resident #82, admitted [DATE], was [AGE] years old with diagnosis of Sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues). Record review of a physician order dated 04/11/23 for Resident #82 indicated Midline catheter to right arm change sterile transparent dressing to insertion site using sterile technique Q (every) weekly and PRN (as needed) if wet, soiled, or not intact. Resident #82 was to receive cefazolin sodium (used to treat bacterial infections) intravenously. Use 2 GM intravenously every 8 hours for infection until 05/09/23. Record review of Resident #82's TAR (treatment administration record) for April 2023 indicated Midline catheter to right arm - change sterile transparent dressing to insertion site using sterile technique Q (every) weekly and PRN (as needed) if wet, soiled, or not intact. Resident #39's midline catheter site dressing had been changed on Sunday 04/16/23, however on this date Resident #82's midline RUA dressing was compromised as it was soiled with dried blood under the transparent dressing. Record review of Resident #82's admission MDS dated [DATE] indicated receiving IV antibiotic medications prior to admission to facility and while in the facility. Record review of Resident #82's care plan dated 04/12/23 gave indication of a midline IV access site. Resident #82's goal was to have no complications related to IV therapy through the next review. Interventions for Resident #82 included changing sterile transparent dressing per physician order and as needed if integrity of dressing is compromised (wet, loose, or soiled). Use a transparent dressing to ensure visualization of the IV site. During observation and interview on 04/19/23 at 2:00 p.m., Resident #82 was sitting in wheelchair visiting with spouse. Resident #82 had a RUA midline IV catheter with a soiled transparent dressing. His had dried blood visible through the transparent dressing. Resident #82 said his IV site dressing had been changed over the weekend. The initials and date were illegible. Resident #82 denied pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675540 If continuation sheet Page 2 of 5 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 675540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Health Care Center 1206 N Travis St Liberty, TX 77575 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or swelling at site. He said he was receiving IV antibiotics for a skin condition. He said he did not know how long the dried blood had been under the transparent dressing. During an observation and interview on 04/19/23 at 2:10 p.m., LVN C acknowledged Resident #82's midline IV dressing was soiled and needed to be changed. She said she would notify the treatment nurse of the situation. During an interview on 04/19/23 at 10:20 a.m., the treatment nurse said she worked Monday-Friday and was responsible for all wound care including IV site dressing changes. She said on the weekends, the weekend RNs were responsible for wound care. The treatment nurse said she had worked at the facility for 2 years and had been the treatment nurse since August 2022. She said she had received training via online classes and hands-on training. She said the nursing staff were scheduled for an in-service training the following day (04/20/23). The treatment nurse said she was supposed to be notified of any new wound/IV orders. She also receives a daily computer print-out of new and/or current wounds and orders. Record review of training in-service indicated most recent in-service on wound care and dressing changes was December 2022 and provided by DON/Regional nurse. Record review of a facility policy dated revised April 2016 and titled, Midline Dressing Changes indicated: . Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter site dressings. General Guidelines. 1. Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675540 If continuation sheet Page 3 of 5 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 675540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Health Care Center 1206 N Travis St Liberty, TX 77575 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 establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and drug records were in order and that an account of all controlled drugs was maintained for 1 of 18 residents (Resident #46) reviewed for pharmacy services. LVN A did not destroy the used fentanyl (scheduled II controlled medication used for severe pain) patch in a sharps container per policy and with a witness for destruction after the patch was removed from Resident #46. The facility did not ensure records for Resident #46 were complete with witness signatures for 5 days on control sheet for disposition of discarded fentanyl patch. This failure could place the residents at risk of drug diversion. Findings included: Record Review of physician orders summary dated April 2023 indicated Resident #46 admitted [DATE] and was [AGE] years old with diagnoses of chronic pain and kidney cancer. The orders indicated to apply 1 fentanyl patch 75 mcg/hour every 3 days and remove patch per schedule. Record review of the significant change MDS assessment dated [DATE] indicated Resident #46 had chronic pain and received pain medication routinely. Record review of Resident #46 medication administration record dated April 2023 indicated a fentanyl patch 75 mcg/hour was ordered every 72 hours, applied transdermal (medication absorbed through the skin) and removed after 72 hours for pain management on the following dates: *04/6/23, *04/9/23, *04/12/23, *04/15/23, *and 04/18/23. Record review of Resident #46's count sheet dated 03/31/23 indicated a fentanyl patch was applied and no witness signatures to indicate the removed used fentanyl patch was destroyed with witnesses on the following dates: *04/6/23, nurse signature was illegible, when the patch was removed and no witness signed, *04/9/23, an unnamed agency nurse signed removing patch and no witness signed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675540 If continuation sheet Page 4 of 5 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 675540 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Health Care Center 1206 N Travis St Liberty, TX 77575 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 *04/12/23, LVN B signed removing patch and no witness signed, Level of Harm - Minimal harm or potential for actual harm *04/15/23, LVN B signed removing patch and no witness signed, *and 04/18/23, LVN A signed removing patch and no witness signed. Residents Affected - Few During an observation on 04/18/23 at 7:43 a.m., LVN A removed the fentanyl patch from Resident #46's chest and placed in the resident's trash. She removed the resident's trash bag with the used fentanyl patch in it, brought it to the soiled linen room, and placed into the trash can. The soiled linen room was not locked. During an interview on 04/18/23 at 7:52 a.m., LVN A said she was trained to throw the fentanyl patch in the trash, bring the trash bag out of the room, and dispose the fentanyl patch in the regular trash can. She said the fentanyl patch could still have medication on the patch. LVN A said she would then sign on the control sheet- sign that she placed a new patch and disposed of the old patch. LVN A denied getting another nurse to witness her dispose of the fentanyl patch for Resident #46. She said she was not trained to use the column which was labeled witness signature. During an interview and record review on 04/18/23 at 8:15 a.m., the DON said she expected the nurses who removed the used fentanyl patch to dispose it in the sharp's container with a witness and both sign the count sheet. She pointed to the count sheet for Resident #46 and said the nurse who witnessed the patch being placed in the sharp's container should have signed in column marked witness signature. The DON said the witnesses did not sign Resident #46's sheet. She said she could not read the signature of the nurse, who removed the patch on 04/06/23. The DON said the documentation on 04/09/23 was an agency nurse. During an interview on 04/18/23 at 8:18 a.m., the administrator said he agreed with the DON about the way the control medication should be handled. During an interview on 04/19/23 at 9:00 a.m., LVN B said on 04/12/23 and 04/15/23 she disposed of the used fentanyl patch in the sharp's container on the medication cart for Resident #46. LVN B said she forgot to get someone to witness her placing the patch in the sharps container and sign the control sheet. She said if they did not get a witness, they could be accused of taking the used fentanyl patches. She said they were trained to have a witness, when disposing of a used fentanyl patch. During an interview on 04/19/23 at 2:00 p.m., the DON said per the facility's policy, the nurses must have a witness to dispose of the fentanyl patch or any controlled medications to prevent drug diversion. Record review of the policy Disposal of medications dated August 2014 . indicated Medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal and state laws and regulations. E. The witnesses of the destruction FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675540 If continuation sheet Page 5 of 5