Inspection·April 10, 2025

F 0641 natural teeth in her oral cavity. Dentist note indicated inflame\swollen, bleeding gums. Level of Harm - Minimal harm or potential for actual harm Review of Resident #31's Care Plan updated 03/26/25 revealed he was care-plan for potential for oral/dental health problem (no tooth) r/t Poor oral hygiene, initiated: 03/26/2025 Revision on: 03/26/2025. Residents Affected - Some Resident #71 Record review of Resident #71's face sheet dated 03/25/25 revealed a-[AGE] year-old male admitted to the facility on [DATE]/2023 and re-admitted on [DATE]. His diagnoses included Essential hypertension (high blood pressure) (Primary diagnosis), dementia with behavior, cellulitis (a bacterial infection of your skin and the tissue beneath the skin), anxiety, depression, and muscle weakness, depression, Infection of amputation of right lower extremities. Review of Resident #71's annual MDS assessment, dated 10/03/24, revealed his BIMS score was 15 out of 15 reflective of intact cognition. Review of section on oral dentures indicated he had all his natural teeth without problem. Observation and interview on 03/24/25 at 8:40 AM revealed Resident #71 was in bed alert and oriented. During an interview, he said he was in pain and had been in pain for a while. He said he has been at the facility for almost 2 years and had lost 4 teeth. He said he was in constant pain and had told the nurse about his pain when unbearable. He reached out to his bed side table and brought out his tube of oral gel. He said he had to order the oral gel online to help with the pain from time to time. He said he gets his medical treatment from the local hospital and that was of no good. In an interview with LVN E on 03/24/25 at 11:00 AM she said she was not aware that Resident #71 had oral dental pain. She said this was her first time of knowing about Resident #71's dental concerns. LVN said Resident #71 was in pain most of the time due to his disease process but did not specify dental pain and he always verbalize relief after 30 minutes of post medication. In an interview with MDS Coordinator A on 03/24/25 at 10:30 AM, She said she was not aware that Resident #71 had dental pain. She said she did not complete Resident #71's MDS assessment. She said Resident #71's MDS assessment was done before her time by another staff that no longer work at the facility. She said she would reassess Resident #71 and refer him to the social worker for immediate referral for his dental problem. In an interview with Facility's social worker on 03/25/25 at 11:00am, she said Resident #71 had sign his dental referral paperwork and she would follow up with the dentist. Observation and interview on 04/10/25 at 12:20pm, revealed Resident #71 had his meal and consumed all served meal 2 slices of [NAME] and vegetables. He said he was doing well and reported no concern. Interview about his pain, he said he had pain from time to time but not current. He said he had pain all over his body and when he had pain, whatever medication that was given for pain, should take care of the pain. He did not tell the staff was specifially his teeth. He said his teeth fell out over a period of one year at different times and not all at once. He also stated he would order his own items like the stuff for his teeth without telling staff. During an interview with CNA G and CNA H on 04/10/25 at 1:50PM, both said they would tell the nurse in charge if a resident complained of pain. CNA G said she has been working with Resident #71 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 2 of 9 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0641 and off for about a year and had not had any complaint. CNA H said she was new but would tell any nurse about residents complaining about pain. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #71's MAR indicated he was on the following medication for pain- Residents Affected - Some Tramadol 100 mg every 8 hours for pain start date 12/07/24 Acetaminophen 325 mg 2 tablets every 6 hours for pain. Nitroglycerin oral PRN for chest pain. Further review revealed he requested pain medications PRN, but his pain level was not above 6 (only 2 times in February 2025) out of 10 being the highest. Record review of Resident #71's weight revealed no evidence of weight loss. His weight was as followed 01/02/25 was 267.7 Ibs, 2/1/25 was 268.5 lbs and 03/01/25 was 261.5Ibs. Weights were completing using a mechanical lift. Record review of Resient #71's current care plan dated April 2025. This care plan revealed resident was seen by the dentist on 3/25/25. A plan was put into place to address his issues. Resident refused care at this time. Resident #77 Record review of Resident #77's face sheet dated 03/26/25 revealed a-[AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included Essential hypertension (Primary diagnosis), bipolar disorder, schizophrenia, anxiety, and depression. Review of Resident #77's annual MDS assessment, dated 4/11/24, revealed her BIMS score was coded as 0 indicated sever cognitive impartment. Review of section on PASRR indicated no mental condition Mental illness was left blank. Review of section I - Active diagnoses, psychiatric \mood disorder was check for bipolar disorder and schizophrenia. Record review of Resident #77's PASRR evaluation dated 12/30/1919 indicated she had serious mental illness. Observation and interview on 03/24/25 at 11:00 AM, revealed Resident #77 was in bed. Resident #77 asked if snacks were available. She said she wanted some snacks. Snacks was requested for her. She said she was doing well and did not answer further question. Record review of Resident #82's electronic face sheet dated 03/26/25 revealed a-[AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included. Absence of right leg Above the knee amputation, type 2 diabetes, (Adult onset of diabetes) dementia, depression, and anxiety dementia behavior, bipolar, anxiety, depression, muscle wasting, essential hypertension (High blood pressure), anxiety and depression. Review of Resident #82's annual MDS assessment, dated 08/02/24, revealed her BIMS score was 11 out of 15 reflective of moderate cognitive impairment. Review of section on oral\dentures status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 3 of 9 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0641 indicated she was assessed as no natural teeth or tooth fragment(s) (edentulous). Level of Harm - Minimal harm or potential for actual harm Observation and interview on 03/25/25 revealed Resident was in her room, alert and oriented, she was on mechanical altered diet . In an interview, she said she had about 5 or 6 teeth in her mouth and the dentist wanted them out, but she was not ready to take them out. Residents Affected - Some Record review of Resident #82's Dental note dated 12/10/24 read in part .Patient treated in room of nursing home. Patient tolerated x-rays well. I recommend an annual exam.; I recommend upper and lower full dentures for teeth replacement as medically necessary to restore proper mastication and nutrition.; I recommend extraction of teeth due to non-restorability as medically necessary to resolve chronic/acute dental infection.; Patient tolerated X-rays well.; Extraction of teeth 6, 7, 8, 20, 22-28 due to decay. During an interview with facility social worker on 03/25/25 at 2:15 pm, she said Resident #71 was not on the dental list, She said she was not aware of Resident #71's dental pain. She said she would follow up with Resident #71. She said Resident #81 had seen the dentist and she would follow up with Resident #81's RP for final decision. She said she was not responsible for completing section L (oral dental) of the MDS. During an interview with MDS Coordinator A on 03/25/25 at 3:30Pm, she looked at all identified MDS and said She was not present at the facility during the time when the identified MDS were completed. She said she was new to the facility and would ensure that all MDS assessment accurately reflected Resident's condition. She said inaccurate assessments could delay\prevent residents from getting needed services to maintain their health. She said she was responsible for ensuring that all assessment reflected resident's health status. Record review of facility's policy titled MDS 3.0 completion, Policy revealed in part Residents are assessed using a comprehensive assessment process in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: I. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 4 of 9 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to refer 1 of 8 residents (Resident #48), reviewed for PASRR screening and evaluations, with a newly evident mental disorder or a related condition for a level II PASRR review. Resident #48 was not referred to the state-designated authority for a PASRR evaluation upon evidence of new diagnoses of bipolar disorder dated 10/16/24 and anxiety disorder dated 10/14/24. These failures placed residents at risk of not receiving adequate services or care related to mental illnesses. Findings included: Record review of Resident #48's admission record dated 10/26/25 revealed a [AGE] year-old female with an admission date of 10/3/22 and a re-admission of 4/1/23. Diagnoses included a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction, (muscle weakness and or partial paralysis of one side of the body that can affect arms, legs and facial muscles as a result of blood flow blockage in the brain) dated 10/3/22, bipolar disorder (condition with episodes of mood swings ranging from depressive lows to manic highs) dated 1016/24 and anxiety disorder (condition with intense excessive and persistent worry and fear about everyday situations) dated 10/14/24. Record review of Resident #48's Q MDS, dated [DATE], revealed the resident had a BIMS score of 11, indicating the resident's cognition was slightly impaired. It also reflected the resident's diagnoses of bipolar disorder and anxiety disorder as active diagnoses coded in section I for active diagnoses. Further record review revealed Resident #48 was coded as taking antipsychotics regularly in section N for medications. Record review of Resident #48's physician's orders, dated 03/27/2025, revealed Resident #48's order for Seroquel oral tablet 25 mg Give 1 tablet by mouth one time a day for bipolar disorder with psychotic features starting active 9/27/23. Record review of Resident #48's PASRR level 1 screening, dated 10/11/22, revealed Resident #48 was coded as No in section C0100 and not having a diagnosis of mental illness. Interview with SW on 3/26/25 at 2:42 pm they said they had completed the PL-1 for Resident #48 back on 10/11/22. They said they did not code Yes in Section C of the PL-1 form because Resident #48 had a primary diagnosis of dementia. The SW said they were told if a resident had a primary diagnosis of dementia, they would not have to code of Mental Illness in section C0100 because the option for Mental Illness would be greyed out and unable to fill. The SW said they were not aware any need for Resident #48 to have a PL-II or evaluation and was unaware of the bipolar and anxiety diagnoses that were added in 2024. The SW said she was helping out with PL-1 completions at the time she completed resident #48's PL-1 in 2022 and had no formal PASRR training at the time she completed the PL-1 for Resident #48. SW said they did receive PASRR training in 2024 and completed an on-line seminar training in November of 2024. Interview with MDS Coordinator A on 3/26/25 at 3:16 pm they said were not aware of any changes to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 5 of 9 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #48's diagnoses and then clarified that the MI diagnoses were not new diagnoses but rather when she started working at the facility they looked back in Resident #48's medical history and found the psychiatric, MI diagnoses and updated Resident #48's diagnoses in 2024, which was after the initial primary diagnosis of dementia in 2022. MDS Coordinator A said they did not believe they had to complete a new PL-1 form, A PL-II or a form1012. MDS Coordinator A said they knew form 1012 for MI existed but was not familiar with how or when to use the form. MDS Coordinator A said they had been an MDS Coordinator for 7 years but had no formal PASRR training at the facility. MDS Coordinator A said if a PASRR was not completed timely or correctly it could result in a resident not being able to receive the services they needed. MDS Coordinator said they had no corporate trainer or training over her department. Interview with DON on 3/27/25 at 4:13 pm they said the MDS and SW departments were responsible for the completion of any and all PASRR forms for the facility. The DON said they did not know who was responsible to ensure the MDS and SW departments were trained on PASRR, and that the Administrator would be the direct oversight or supervisor for those two departments. Interview with Administrator on 3/26/25 at 5:15pm they said staff had been trained on PASRR and would have to check and see when MDS Coordinator A and SW had completed their trainings. The Administrator was unaware of the diagnosis changes and or updates that had been made for Resident #48. Record review on 3/26/25 at 8:32pm of email sent by administrator that provided certificates of training for Administrator. The email said that read in part: Attached you will find my Certificate of Completion for the 'IDD Services PASRR Conference Online held on November 7, 2024. Other participants from this facility who attended included MDS Coordinator A, SW, and DON. They are going to look for their Certificates of Completion. MDS Coordinator B started working at this facility in January 2025. She said that she participated in the November 7, 2024, training also. We also participated in Training on September 25, 2024, during a Quality Monitoring Visit. I have documentation from this training also. The administrator only provided evidence of her completions of any PASRR trainings prior to facility exit. 03/27/25 11:34 am Follow up interview with MDS Coordinator A on 3/27/25 at 11:34 am who said they initiated a form 1012 for Resident #48. MDS Coordinator A did not provide a copy of the form and said they submitted it for a physician to complete as it required a physician signature. Record review of facility's policy titled; PASSR dated 06/2022 read in part: This Mental Disorder is a schizophrenic, mood, paranoid, panic or other severe panic disorder, somatoform disorder, personality disorder other psychotic disorder or another mental disorder that may lead to a chronic disability but not a primary diagnosis of dementia . 1. All residents will have a PASSR PL-1 completed prior to admission to facility . PASSR level II evaluation will determine whether the individual has an MI or DD or related condition, as well as what setting, and services would best suit their needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 6 of 9 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 10% based on 3 out of 30 opportunities, which involved 3 of 3 residents (Resident #25, Resident #54, and Resident #93) and 2 of 2 staff (LVN and MA A) observed during medication administration reviewed for medication error. Residents Affected - Some 1. The facility failed to ensure that Resident #25's aspirin was administered as ordered as chewable on 3/25/25 at 8:50 a.m. as the aspirin was swallowed whole. 2. The facility failed to ensure that Resident #54's Cholecalciferol Oral Tablet 50 mcg was administered as ordered on 3/25/25 at 9:02 a.m. as D3 125 mcg (5000 IU) was administered. 3. The facility failed to ensure that Resident #93's aspirin was administered as ordered as chewable on 3/25/25 at 8:38 a.m. as the aspirin was swallowed whole. The failure could place residents at risk of not receiving therapeutic dosage and/or effects of medications. Findings included: Resident #25 Record Review of Resident #25's face sheet dated 3/26/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (chronic lung condition causing restricted airflow), Atherosclerotic Heart Disease of Native Coronary Artery (buildup of plaque in arteries that supply blood to the heart), and Essential Hypertension (High Blood Pressure). Record review of Resident's #25's quarterly MDS dated [DATE] revealed a BIMS score of 5 that suggested severe cognitive impairment. Record review of Resident #25's Order Summary Report as of 3/25/25 revealed order for Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for Blood thinner. Record review of Resident #25's MAR printed 3/25/25 revealed Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day. Observation on 3/25/25 at 8:50 a.m. revealed LVN H administered Chewable Aspirin 81 mg with Resident #25's other medications which he swallowed and was not chewed. LVN H did not instruct Resident #25 to chew the aspirin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 7 of 9 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 Resident #54 Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #54's face sheet dated 3/26/25, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities), Osteitis Deformans (chronic bone disorder with excessive breakdown and regrowth of bone). Residents Affected - Some Record review of Resident #54's quarterly MDS dated [DATE] revealed a BIMS score of 1 that suggested severe cognitive impairment. Record review of Resident #54's Order Summary Report as of 3/25/25 revealed order for Cholecalciferol (Vitamin D3) Oral Tablet 50 mcg (2000 UT ) Give1 tablet by mouth one time a day for vitamin d deficiency. Record review of Resident #54's MAR printed 3/25/25 revealed Cholecalciferol Oral tablet 50 mcg (2000 UT) Give 1 tablet by mouth one time a day. Observation on 3/25/25 at 9:02 a.m. revealed that LVN H administered D3 125 mcg (5000 IU) to Resident #54. Resident #93 Record Review of Resident #93's face sheet dated 3/26/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Peripheral Vascular Disease (disorder of the blood vessels), Atherosclerosis (plaque buildup in blood vessels that carry blood through the body) and Congestive Heart Failure (disorder where the heart does not pump blood as well as it should). Record review of Resident's #93's quarterly MDS dated [DATE] revealed a BIMS score of 6 that suggested severe cognitive impairment. Record review of Resident #93's Order Summary Report as of 3/25/25 revealed order for Aspirin 81mg Oral Tablet Chewable 81 mg (Aspirin) Give 1 tablet by mouth one time a day for prevent blood clot. Record review of Resident #93's MAR printed 3/25/25 revealed Aspirin 81 Oral Tablet Chewable 81 mg (Aspirin) Give 1 tablet by mouth one time a day for prevent blood clot. Observation on 3/25/25 at 8:38 a.m. revealed LVN H administered Chewable Aspirin 81 mg with Rresident #93's other medications which he swallowed and was not chewed. LVN H did not instruct Resident #93 to chew the aspirin. Interview on 3/27/25 at 9:56 a.m., ADON said staff have continuing education training regarding medications. Interview on 3/27/25 at 10:02 a.m., MA A said there is was a class yearly for continuing education regarding medication with a written exam. Interview on 3/27/25 at 10:07 a.m., the DON said that the facility uses a computer- based training system with medication education done quarterly with competency- based check offs and further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 8 of 9 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 675791 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Golfcrest 7633 Bellfort Houston, TX 77061 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 education done as needed. The DON said that the pharmacist observes medication pass at the facility. The DON said that if aspirin or other medications is was not administered correctly or at the correct dosage, then the resident might not get the therapeutic effects of the medication. Interview on 3/27/25 at 10:34 a.m., the Pharmacist said she does medication training quarterly and monthly during the facility's survey window to all nursing staff. Record Review of policy Medication Administration with implementation date of 3/2022 revealed that medications are to be administered as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675791 If continuation sheet Page 9 of 9