Inspection·June 22, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 in her room. LVN A asked Resident #1 which finger she wanted to use. Resident #1 picked her middle finger and LVN A rubbed the area with an alcohol swab. LVN A checked Resident #1 sugar levels. LVN A said Resident #1's sugar level was 228. LVN A held another alcohol swab in the same area Resident #1's blood sugar was checked and lightly pressed the area to stop the bleeding. LVN A reached to get the insulin to administer it to Resident #1. Surveyor asked LVN A was she sure that was the correct insulin pen and LVN A said yes. Surveyor asked LVN A to see the insulin pen before she administered it to Resident #1. Surveyor asked LVN A to see the insulin cap as well. Observation revealed the insulin cap had Resident #2's name on it. Upon further observation revealed the insulin LVN A was about to administer to Resident #1 was Tresiba FlexTouch U-100 insulin 100 unit/mL (3mL). Surveyor asked LVN A to take a second look at the insulin pen cap label. LVN A went back to retrieve the correct insulin for Resident #1 after Surveyor intervention. During an interview on 6/20/2023 at 4:58pm with Director of Nursing, she said she was not aware of a resident receiving another resident's insulin. She said LVN A shared Surveyor's intervention regarding Resident #1's insulin belonging to Resident #2. She said she looked in the med-cart and found two different insulins. She said she had no idea how long this could have been going on. She said the nurses have oversight of their med-carts. She said the med carts should be checked before every med pass. Surveyor asked the DON what the difference between Tresiba FlexTouch U-100 insulin 100 units/ml (3ml)13 units and Humalog Kwik Pen insulin 100 unit/ml. She was said the Tresiba medication was long-acting insulin. She said the Humalog Kwik pen medication was the short acting insulin. She said if the Tresiba was given to Resident #1 it would lower her blood sugar. She said after looking at Resident #1's chart she ran high with her blood sugars. She said if she was aware Resident #1 was given Tresiba the resident would be monitored for any adverse reactions. She said the protocol for medication error was the nurses would inform the DON, the nurses would call the physician to advise the med error of the resident so the physician would give orders and instructions on what to do next for the resident. She said the nurse had to notify the family and during the entire process the resident was being monitored. She said an incident report was documented. She said the last time nursing staff were trained for medication administration was on 6/12/23 and LVN A participated in the training. She said LVN A training consisted of completing her med pass with the Pharmacist. She said the Pharmacist required nursing staff to conduct a return demonstration post training. She said the Pharmacist was responsible for the accuracy of med pass. During an interview on 6/20/23 at 6:19pm with LVN A, she said she was familiar with Resident #1 because she conducted med pass in Hallway 100 where Resident #1's room was located. She said she had never had a med error in the 14 years working at the facility. She said the facility's protocol for insulin administrations was to check the computer orders for the resident, gather supplies, wipe down and disinfect her hands, knock on the door, and let the resident know what was about to happen. She said she sanitized her hands and donned (put on) gloves to do blood sugar test, she made sure the resident was no longer bleeding by using the alcohol swab and applying pressure. She said once she receives the number from the blood sugar reader, she notates it in the computer. She said she would remove her gloves and sanitized her hands before going back into the computer and double checking the insulin order to see what was needed for the resident. She said she crossed-checked between the insulin and the computer to ensure accuracy. She said she scrolled to the appropriate amount, crossed-checked the insulin with the resident's name, checked the dosage to ensure she had the right number of units. She said she sanitized her hands and donned gloves, told the resident what she was about to do, and crossed checked a second time to ensure she had the right insulin and the right route (giving insulin from a pen and not a bottle) and disinfected the area with alcohol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 2 of 3 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 675663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fort Bend Healthcare Center 3010 Bamore Rd Rosenberg, TX 77471 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 and administered the insulin. She said she made a mistake with Resident #1's insulin orders because this Surveyor made her nervous. She said she would check the refrigerator if Resident #1's insulin pen was not in the med cart. Secondly, she said would go to the emergency kit in the refrigerator for Resident #1 insulin pen. She said she had always tried to be as careful as possible to prevent harm to the residents. She said if she was to give a resident the wrong insulin, she would immediately inform the doctor, await new orders, while waiting take vitals of the resident, and monitor any changes and conditions, side effects the resident might experience, as well as inform the family and contact the DON. During an interview on 6/20/2023 at 7:14pm with the Executive Director, he said he was informed by the nurse (LVN A) that she had a problem with the medication administration. He said she said she was trying to administer the wrong medication to the wrong resident. He said this was a critical factor for any resident. He said he was going to implement a process for nursing staff to have a verification process in place to ensure the correct insulin medication was administered. He said he was going to get the Director of Nursing to train nursing staff and the key to the training was to ensure the nurses were giving the right medication and the correct route to the correct resident. He said he always addressed any issues the family or residents brought to his attention. In a follow-up interview on 6/20/2023 at 8:20pm with the Director of Nursing she said all licensed nurses would be trained and monitored on the six rights of medication administration (The basis for medication administration for nurses). She said there would be a second nurse who would go back to check the insulin and dosage before administration as well as nursing staff putting their signatures on an auditing form. Record review of the facility's Administering Medication policy titled; Policy Interpretation and Implementation dated April 2019 read in part . (4) Medications are administered in accordance with prescriber orders . (9) The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: (c) if necessary, verifying resident identification with other facility personnel .(10) The individual administering the medication checks the label Three(3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the right medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675663 If continuation sheet Page 3 of 3