Health inspection·December 8, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings included: 1. Record review of Resident #1's Face Sheet, dated 10/23/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obesity (excessive accumulation of body fats) and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #1's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 10/02/2025, reflected the resident had as severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 03. The Comprehensive MDS Assessment indicated the resident had dementia and obesity. Record review of Resident #1's Comprehensive Care Plan, dated 10/12/2025, reflected the resident had the potential for impaired skin integrity and one of the interventions was to provide proper skin care. Record review of Resident #1's Physician Order, dated 10/08/2025, reflected Apply Antifungal powder to groin area after each perineal (area between the thighs) care. every shift for Skin redness AND as needed. Record review of Resident #1's Assessment Notes on 10/23/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment the resident was competent to manage their own medications. During an observation and interview on 10/23/2025 at 8:43 AM revealed Resident #1 was in her bed eating breakfast using her overbed table. It was observed that an anti-fungal powder was also on top of the overbed table and was in plain view. The resident gestured that it was used on her groin. The resident shook his head when asked if he was applying the anti-fungal. 2. Record review of Resident #2's Face Sheet, dated 10/23/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression. Record review of Resident #2's Comprehensive MDS Assessment, dated 09/24/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had depression. Record review of Resident #2's Comprehensive Care Plan, dated 10/17/2025, reflected the resident had depression and the interventions were to administer antidepressant and monitor effectiveness. Record review of Resident #2' Physician Order on 10/23/2025 reflected the resident did not have orders for Systane eyedrops. Record review of Resident #2's Assessment Notes on 10/23/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administration, and no assessment the resident was competent to manage their own medications. During an observation and interview on 10/23/2025 at 9:06 AM revealed Resident #2 was in her bed, awake. It was observed that three bottles of Systane eyedrops were on top of the resident's overbed table and were in plain view. The resident said the eyedrops had always been on top of her table. She said she was not using them. 3. Record review of Resident #3's Face Sheet, dated 10/23/2025, reflected a [AGE] year-old female admitted to the Page 1 of 3 675811 675811 12/08/2025 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE]. The resident was diagnosed with depression. Record review of Resident #3's Comprehensive MDS Assessment, dated 08/27/2025, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had depression. Record review of Resident #3's Comprehensive Care Plan, dated 10/12/2025, reflected the resident had depression and one of the interventions was to administer medications as ordered. Record review of Resident #3' Physician Order on 10/23/2025 reflected no order for nasal spray. Record review of Resident #3's Assessment Notes on 10/23/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administration, and no assessment the resident was competent to manage their own medications. During an observation and interview on 10/23/2025 at 9:13 AM revealed Resident #3 was in her bed, awake. It was observed that a nasal spray was on top of the resident's dresser. The dresser was located few steps away from the door and the nasal spray was on plain view. When asked about the nasal spray, the resident did not reply. In an interview on 10/23/2025 at 10:07 AM, LVN C stated there should be no medications inside the rooms of the residents unless they had an assessment that they could self-administer their medications. He said it might result in overmedication and adverse reactions. He said the residents might be taking them every hour and nobody would know. He said confused residents might enter the room, get ahold of the medications, and consume them. He saw Resident #1's anti-fungal and said he had not applied yet the resident's anti-fungal so he did not know who left the anti-fungal on top of the Resident #1's overbed table. He said the resident might be confused or have poor eyesight and put the anti-fungal powder on her food. He saw Resident #2' eye drops and Resident #3's nasal spray and said he did not notice the medications when he did his morning rounds. He said the medications should be inside the cart and the staff should be the ones administering it. He said he would contact the residents' family member to know if the eye drops and nasal sprays were needed by the residents so he could request orders for the said medications. In an interview on 10/23/2025 at 11:45 AM, ADON A stated medications should be inside the carts and not inside the residents' rooms because the residents might be confused and use the medications as often as they wanted without anybody monitoring it. She said other confused residents might enter the room, use the medications, and might be allergic to it. She said the anti-fungal was a medicated powder and should not be beside the food tray because the resident might put it on her food. She said anything could happen. She said the Systane eyedrops and the nasal spray should have been seen if the medications were in plain view. She said those medications should be administered by the staff and must have physician orders. She said confused residents might use the medications other than ocularly and nasally. She said the expectation was for the staff would make a conscious effort of checking for any medications inside residents' rooms. She said she would coordinate with the DON to do an in-service about medication storage. In an interview on 10/23/2025 at 11:17 AM, ADON B stated she was also the wound care nurse. She said Resident #1 had redness on her groin, that was why she had an order for an anti-fungal. She said the anti-fungal powder should be inside the cart and the nurses were the ones administering it because it was a treatment. She said residents might consume it and might have stomach issues. She said there should be no medications inside the residents' rooms because the residents might misuse them. She said the nasal spray was just sodium chloride but some residents might get ahold of it and might be allergic to it. She said residents might also poke their eyes if they were administering the eyedrops by themselves. In an interview on 10/23/2025 at 12:07 PM, the DON stated medications could be inside the residents' rooms if they have an assessment that they self-administer. She said the risk could be inappropriate use and inappropriate consumption. She said the facility had residents that would sometimes go inside other residents' rooms and might take 675811 Page 2 of 3 675811 12/08/2025 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the medications, especially if the medications were in plain view. She said the anti-fungal was taken out from the room. She said they would talk to Resident #2 about her eye drops and educate her that the staff should be the one administering it. She said they would also communicate with the family members to let them know if they were bringing any medications. She said they would check the rooms to see if there were any medications inside and would start an in-service about medication storage. In an interview on 10/23/2025 at 12:25 PM, the Administrator stated he was made aware of the medications observed inside the residents' rooms. He said the medications should be inside the carts and should be applied by the nurses to prevent any harm to the residents. He said the DON already started an in-service about medication storage and he would also send letters to the families regarding letting them know if they were bringing any medication for the residents. Record review of the facility's policy entitled, Storage of Medications 2001 MED-PASS, Inc. revised April 2019 reflected Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation . 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls . 3. The nursing staff is responsible for maintaining medication storage. 675811 Page 3 of 3