Health inspection·July 13, 2023

F 0656 Further review revealed recommendation to continue with bed rail(s). Level of Harm - Minimal harm or potential for actual harm Observation and interview on 07/11/2023 at 10:01 a.m. of Resident #44 was completed. Resident was observed lying in bed reading a book. Her bed frame did not have attached bed rails. She said she wanted to know why she could not have bed rails. She said she used to have bed rails but did not know why she no longer had them. She said the bed rails helped her to reposition herself. Residents Affected - Few Observation on 07/12/2023 at 12:30 p.m. revealed Resident #44's bed frame did not have attached bed rails. In an interview on 07/12/2023 at 4:56 p.m., the DON said Resident #44's assessment, consent, and orders for the bed rails were completed. He said the bed rails were also care planned. He said he did not know why the rails had not been installed. He said the resident's bed had switched a lot since she was admitted to the facility. He said the nurse was responsible for ensuring the bed rails were implemented. He said he talked with the nurses and was not able to determine who and when the bed was changed out last. He said the risk posed to the resident from not receiving the bed rails was that it could make it more difficult for them to turn . Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, read in part . .4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: g. receives the services and/or items included in the plan of care FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675701 If continuation sheet Page 2 of 10 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 675701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lawrence Street Health Care Center 615 Lawrence Street Tomball, TX 77375 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessment for 1 of 17 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7's care plan was revised to include interventions for falls to help prevent injuries. This failure could place residents at risk of not having their needs addressed and inconsistency of care. Findings include: Record review of Resident #7's face sheet, dated 07/13/2023, revealed a [AGE] year-old male who was admitted into the facility on [DATE]. The resident had diagnoses which included alcohol dependence with alcohol-induced persisting dementia, degenerative disease of nervous system, hypertension, and quadriplegia. Record review of Resident #7's admission MDS, dated [DATE], revealed the resident was assessed to need substantiated to maximal assistance with transfer and the resident was assessed to have had a fall within the last month prior to admission. The resident's BIMS score was 7, which indicated the resident's cognition was severely impaired. Record review of Resident #7's care plan, last revised on 07/13/2023, revealed Resident #7 had actual falls related to poor balance, poor safety awareness and unsteady gait and actual falls occurred on 05/01/2023 due to sliding off the bed, and on 05/05/2023, 05/21/2023, 05/30/2023 and 06/08/2023. The intervention of a fall mat use for resident falls was added after State Surveyor intervention on 07/13/2023. Observation and interview on 07/11/2023 at 10:15AM, revealed Resident #7 was lying in bed with a fall mat to the side of his bed and stated he could get around okay on his own without assistance. In an interview on 07/13/2023 at 3:12PM, CNA T stated Resident #7 did not know how to use his call light and managed multiple times to transfer himself in his chair even with the wheelchair placed out of reach. She stated the resident had a fall mat since he was first admitted , in April 2023 and she believed the resident needed the mat to prevent him from acquiring bruises when he fell after scooting himself out of bed and onto the floor. In an interview on 017/17/2023 at 3:24PM, LVN A stated Resident #7 needed the fall mat because she believed he had a condition similar to restless leg syndrome which caused the resident to often scoot to the edge of his bed and increased his risk of falling. She stated the fall mat was used and should be listed on his care plan as one of his interventions for falls. In an interview on 07/17/2023 at 3:35 PM, the DON stated Resident #7's care plan needed to be updated to ensure all necessary interventions for falls were listed in his care plan to ensure he was not at increased risk for injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675701 If continuation sheet Page 3 of 10 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 675701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lawrence Street Health Care Center 615 Lawrence Street Tomball, TX 77375 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility's policy on Falls, revised March 2018, stated, . If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions Record review of the facility's policy on Care Plans, revealed, no information regarding revision timing of care plans. Event ID: Facility ID: 675701 If continuation sheet Page 4 of 10 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 675701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lawrence Street Health Care Center 615 Lawrence Street Tomball, TX 77375 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 - 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, interview and record review the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and the facility failed to determine that drug records were in order and that an account of all controlled drugs were maintained periodically reconciled for 1 of 7 residents (Resident #15) reviewed for medication administration and 1 of 2 medication carts (B Hall medication cart) reviewed for accounting. 1. The facility failed to ensure an accurate recordkeeping of liquid Lorazepam (a controlled substance) from the B Hall medication cart. 2. The facility failed to check Resident #15's blood pressure prior to administering Metoprolol used to treat high blood pressure. 3. The facility failed to ensure Resident #15 received the prescribed nebulizer treatment by leaving the medication at the bedside for the resident to self-administer. The resident did not have an order to self-administer the medication. Findings include: 1. Observation and record review on 07/12/2023 at 9:35 AM revealed the B hall medication cart's locked narcotic compartment contained a bottle of Lorazepam 2mg/1ml which contained between 10ml and 12ml of fluid according to the measurements on the side of the bottle label. The controlled drug receipt/disposition form listed the following entries: -06/05/2023 at 5:30 PM, RN B documented 0.5ml was given and the amount left in the bottle was 16 ml. -06/10/2023 at 5:30 PM, RN A documented 0.5ml was given and the amount left in the bottle was 15.5ml. -07/07/2023 at 10:00 AM, RN A documented 0.5ml was given and the amount left in the bottle was 15ml. -07/07/2023 at 1:00 PM, RN A documented 0.5ml was given and the amount left in the bottle was 14.5ml. -The last entry was on 07/09/2023 at 10:00 AM, RN A documented that 0.5ml was given and the amount left in the bottle was 14ml. In an interview on 07/12/2023 at 9:35 AM, RN A stated the bottle of Lorazepam came from Hospice Services. RN A stated she would notify the DON about the discrepancy between the amount left in the bottle and the balance written on the narcotic sheet. In an interview on 07/13/23 at 9:45 AM, the DON stated the bottle of liquid Lorazepam 2mg/ml contained 11.5ml. The DON stated the nurses needed to track this more closely and that he did not think there would be any problems with controlled medications in liquid form. In an interview on 07/13/23 at 9:50 AM, RN B stated it was his signature on the controlled drug receipt/disposition form for the Lorazepam 2mg/ml from 05/24/23 to 06/05/23. RN B stated the liquid in the bottle was hard to see and he always compares what was in the bottle to what was written on the form. RN B stated on 06/05/23 the count was correct and he did not know why there was a discrepancy on 07/09/23 because he did not sign anything out after 06/05/23. RN B stated the nurses were responsible for documenting accurately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675701 If continuation sheet Page 5 of 10 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 675701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lawrence Street Health Care Center 615 Lawrence Street Tomball, TX 77375 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 - Some In an interview on 07/13/23 at 10:50 AM, RN A stated it was her signature on the controlled drug receipt/disposition form for the Lorazepam 2mg/ml from 06/10/2023 to 07/09/2023. RN A stated the liquid tended to leak around the syringe and bottle whenever a dose was removed, and this would account for some liquid loss. RN A stated she was responsible for documenting accurately on the sheets. RN A stated when discrepancies were found, then corrections were made. RN A stated moving forward corrections would be made in time and hoped they would get prefilled syringes instead. In an interview on 07/13/23 at 1:30 PM, the DON stated the liquid Lorazepam estimated loss was 6 doses based on each administered dose being 0.5ml and the estimated volume remained was closer to 11ml. The DON stated moving forward it was decided a self-report would be submitted and all staff who had access to the box would be drug tested in case of drug diversion. The DON stated the facility would no longer accept multidose liquid bottles of controlled medications d/t the difficulty to accurately track the remaining volume of liquid. The DON stated the manufacturer label on the bottle read: approximate volume of solution was in the bottle. Record review of the NDC 0054-3532 Lorazepam label information solution, concentrate oral, details, usage, and precautions, ndclist.com, revised February 2017, read in part: .Lorazepam is a federal controlled substance (C-IV) because it can be abused or lead to dependence. Keep Lorazepam in a safe place to prevent misuse and abuse. Selling or giving away Lorazepam may harm others and is against the law . Record review of the facility's policy for Controlled Substances, revised April 2019, read in part: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .10. Upon Administration: a. The nurse administering the medication is responsible for recording . (5) quantity of the medication remaining .12. At the end of each shift: A. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. B. Any discrepancies in the controlled substance count are documented and reported to the director nursing services immediately. C. The director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties and reports the findings to the administrator. D. The director of nursing services consults with the provider pharmacy and the administrator to determine whether further legal action is indicated .1. Policies and procedures for monitoring-controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist. Record review of the facility's policy for Medication ordering and Receiving from Pharmacy, revised August 2014, read in part: Medication Packaging, medications are provided in packaging to facilitate accurate administration and accountability of the medication. All packaging meets USP (United States Pharmacopeia) standards . 2. Record review of Resident #15's admission record face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included critical illness myopathy (a disease of limb and respiratory muscles observed during treatment in the intensive care unit), obstructive sleep apnea (a sleep related breathing disorder), HTN (elevated blood pressure), hyperlipidemia (elevated fats in the blood), morbid obesity, heart disease, atrial fibrillation (irregular, rapid heart rhythm), lymphedema (tissue swelling), depression, and urinary tract infection (an infection that affects any part of the urinary system). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675701 If continuation sheet Page 6 of 10 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 675701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lawrence Street Health Care Center 615 Lawrence Street Tomball, TX 77375 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 - Some Record review of Resident #15's admission MDS, dated [DATE], revealed she had a BIMS score of 15, which indicated intact cognition. She required extensive assistance with most ADLs. She required oxygen therapy and non-invasive mechanical ventilator (BIPAP-therapy to treat sleep apnea). Record review of Resident #15's physician order summary report, as of 07/11/2023, revealed an order for Budesonide inhalation suspension 0.5/2ml, one application inhale orally two times a day for shortness of breath. The order date was 06/25/2023. Metoprolol succinate ER oral tablet extend release 24 hours 25mg, give one tablet by mouth two times a day for BP. Hold for SBP less than 110 and DBP less than 60 or HR less than 60. The order date was 06/25/2023. Further review of the physician order revealed there was no order for self-administration of medications. Record review of Resident #15's, undated, care plan revealed she had the potential for impaired gas exchange r/t exhibiting SOB/trouble breathing when laid flat. Interventions included: check O2 saturations and provide respiratory treatments as ordered. Further review of the care plan revealed there was no plan addressing the diagnosis of hypertension. During observation and interview of a medication pass on the evening of 07/11/2023 at 8:15 PM, LVN B administered medications to Resident #15 which included Metoprolol ER 25mg oral tablet. LVN B then checked Resident's BP on her right wrist using a wrist BP monitor. LVN B said the BP was 71/30 and it was too low. LVN B checked her oxygen saturation rate on her right hand, and it was 97% and the pulse was 61. LVN B checked Resident #15's BP on her left arm using a manual BP cuff and stethoscope. LVN B wrapped the BP cuff upside down around the resident's left forearm, instead of the upper arm and with the BP tubing pointing towards the shoulder. LVN B placed the bell of the stethoscope at the anterior aspect of the elbow joint. LVN B said the BP reading was 124/72. LVN B poured the liquid Budesonide inhalation suspension 0.5/2ml into the chamber of the nebulizer tubing, reattached the nebulizer face mask then hung the strap of the facemask onto a basket that was on the bedside table and moved the bedside table closer to the resident. LVN B asked the resident if she could reach the equipment. The compressor nebulizer machine was turned off and was on top of the nightstand within the resident's reach. Resident #15 stated she could reach the mask as well as the machine and would start the breathing treatment when she could bend her right arm after the IV was complete. LVN B walked out of the room and said he would check on her later. LVN B stated he forgot to check her BP before administering the Metoprolol. LVN B stated the risk to the resident was the BP could drop. LVN B stated he used a medium BP cuff because there was no larger cuff available. LVN B stated he was ex-military and checking BP on the lower arm was what was done out in the field. LVN B stated he knew checking the BP on the forearm would result in a reading that would be off and not as accurate. LVN B stated checking the BP this way was not facility policy. LVN B stated he should have re-checked using the wrist BP monitor on the resident's left wrist. LVN B had no explanation as to why he didn't do this instead of using the manual cuff. LVN B stated it was not the facility policy to leave the breathing treatment medication at the bedside and then walk away. LVN B did not have an explanation as to why he walked away with the medication at the bedside. LVN B returned to the resident's room and emptied the nebulizer chamber of the liquid Budesonide. LVN B stated he would return after the IV was completely infused, administer the nebulizer treatment, and make sure the resident took the medication correctly before walking out of room. LVN B stated he usually checked the resident's vitals before administering medications, but he was thrown off his routine d/t earlier issues with another resident. In an interview on 07/12/2023 at 6:50 PM, the DON stated the nurse was supposed to check Resident #15's BP before administering the Metoprolol and to use the manual BP cuff correctly by wrapping the cuff around the upper arm with the tubing pointing down the arm. The DON stated the facility did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675701 If continuation sheet Page 7 of 10 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 675701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lawrence Street Health Care Center 615 Lawrence Street Tomball, TX 77375 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 - Some have a large BP cuff available but would check the cart to make sure. The DON stated LVN B was trained on the use of a BP cuff. The DON stated the nurse was not supposed to leave the Budesonide breathing treatment at the bedside and walk away. The DON stated, normally the facility staff went over self-administration of medications with the resident and then got an order from the physician. The DON stated the risks of leaving a breathing treatment for the resident to self-administer would be infection as it would be unsanitary to just leave it, the resident may not receive the full treatment and the nurse was supposed to monitor and ensure the resident was tolerating the treatment well. The DON stated LVN B did not follow policy. The DON stated he expected a self-administration order in place prior to leaving a resident with any medication. The DON stated he would conduct a one-on-one training with LVN B. The DON stated the facility did not have a written policy and procedure for the use of blood pressure cuffs. Record review of Resident #15's, blood pressure summary revealed LVN B rechecked her blood pressure on 07/12/2023 at 12:24 AM. The result was 121/72 lying down taken on the right arm. Record review of LVN B's Competency Checklist, dated 2/26/2023, revealed he did not require further training and the competency was completed on 3/23/2023. The checklist included medications administration and vital signs which included blood pressure. The checklist included performing nebulizer treatments. Record review of the facility's policy for Administering Medications, revised April 2019, read in part: Policy heading - Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frame .11. The following information is checked/verified for each resident prior to administering medications .b. Vital signs, .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely Record review of the facility's policy for Administering Medications through a Small Volume (Handheld Nebulizer, revised October 2010, read in part: Purpose - the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .Steps in the Procedure .13. Turn on the nebulizer and check the outflow port for visible mist .17. Remain with the resident for the treatment .18. Approximately five minutes after treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness, and nervousness throughout the treatment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675701 If continuation sheet Page 8 of 10 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 675701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lawrence Street Health Care Center 615 Lawrence Street Tomball, TX 77375 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 - 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. Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for two of two medication carts (B Hall medication cart and medication cart in the secure unit) reviewed for storage of medications. 1. The facility failed to ensure B Hall medication cart and the medication cart in the secure unit did not contain torn protective seals on the back of narcotic medication blister pill cards. 2. The facility failed to ensure the B Hall medication cart did not have loose pills. 3. The facility failed to ensure eye drops were labeled and medications had the expiration dates in the B Hall medication cart. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings include: 1. Observation on 07/12/2023 at 9:35 AM of B Hall medication cart revealed the locked narcotic storage compartment contained 10 tablets of Lorazepam 0.5 mg in a blister card. Blister compartment number 10 had a torn seal that was taped closed on the back of the blister card. The narcotic count for the Lorazepam was accurate. There were loose pills found at the bottom of the second drawer: one small round pink pill with number 1081 and one small round white pill with numbers 502. A packet of AZO Urinary Pain relief tablets in a blister type package contained 20 brown tablets were found in the top drawer. The package did not have an expiration date. The original package was not in the cart. There were 2 bottles of artificial tears lubricant eye drops in the top drawer. The bottles and the box for the eye drops did not have resident identifiers or an opened date. Both bottles contained fluid. In an interview on 07/12/2023 at 9:35 AM, RN A stated the Lorazepam was taped probably because the back of the package had a tear. RN A stated the tablet should be discarded d/t the risk of infection and the tablet could have been replaced with a different tablet that was not Lorazepam. RN A stated she would notify the DON and the tablet would be destroyed per facility policy. RN A stated the nurses were responsible for maintaining the medication carts and she cleaned the cart regularly. RN A stated the loose pills could fall out and someone could take it and it could cause harm to them. RN A stated the AZO Urinary Pain relief tablets should have expiration dates like all the other medications in the cart. RN A stated both bottles of artificial tears had been opened because the seals were gone and some of the liquid had been used. RN A stated she had not used the bottles and did not know how they got in the cart or which resident they would have been used for. RN A stated she would notify the DON and put the bottles and the packet of urinary pain relief tablets in the medication destruction box. RN A stated the risk of using these bottles of artificial tears on a resident would be eye infection because the same bottle of eye drops should not be used on different residents. 2. Observation on 07/12/2023 at 4:00 PM of the medication cart in the secure unit revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675701 If continuation sheet Page 9 of 10 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 675701 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lawrence Street Health Care Center 615 Lawrence Street Tomball, TX 77375 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 - Some locked narcotic storage compartment contained 31 tablets of Lorazepam 0.5 mg in one blister card. Blister number 18 had a tear on the back of the package. A second Lorazepam 0.5 mg blister card contained 9 tablets. Blister number 8 had a tear on the back of the package. The narcotic count for the Lorazepam was accurate. In an interview on 07/12/2023 at 4:00 PM, LVN A stated the risk of having the Lorazepam with a tear in the packaging was the pill could fall out, a resident might pick it up, eat it and they may get harmed. LVN A stated the risk could also be loss of medication supply for the resident it was intended for. LVN A stated she would go to the DON for advice on what to do with the tablets. In an interview on 07/12/2023 at 4:00 PM, the DON stated the Lorazepam with the torn seal should be discarded. In an interview on 07/12/2023 at 6:50 PM, the DON stated the nurses were supposed to maintain the cart daily as needed. The DON stated if a medication should drop, they were supposed to destroy it and the risks would be someone could steal the Lorazepam tablet or someone could accidentally pick it up and ingest it. The DON stated his expectation was the nurses double checked the narcotic medication count against the count sheet for accuracy, loose pills and pills in torn controlled substance blister cards should be destroyed. The DON stated the nurses were responsible for discarding medications per facility policy and the DON or the ADON were responsible for conducting nursing staff in-services covering medications and controlled substances. The DON stated he was unsure when the last in-service took place. Record review of the facility policy for Controlled Substances, revised April 2019, read in part: Policy Statement: The facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation .8. Controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift . Record review of the facility policy for Storage of Medications, revised November 2020, read in part: Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation .2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Record review of the facility policy for Medication Storage in the Facility, revised August 2014, read in part: B. Drug dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date .D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1)The nurse shall place a 'date opened' sticker on the medication and enter the date opened and the new date of expiration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675701 If continuation sheet Page 10 of 10