Health inspection·March 26, 2025

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 ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of X residents (Resident #1's) reviewed for drug diversion. The facility failed to prevent an employee with access to controlled medications from diverting 44 Tablets of Hydrocodone-Acetaminophen 10-325 MG tablets (a schedule II-controlled substance opiate used to treat pain) belonging to Resident #1 from a medication cart. The noncompliance was identified as PNC. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for unrelieved pain due to his medication not being readily available. Findings included: Record review of Resident #1's Face Sheet, dated [DATE], reflected an [AGE] year-old female, who most recently admitted to the facility on [DATE]. Resident #1 had a diagnosis which included senile degeneration of brain (a decline in cognitive functioning), malignant neoplasm of colon (cancer of large intestine), and intra-abdominal and pelvic swelling (growth or swelling in abdomen). Record review of Resident #1's Physician orders dated [DATE], reflect she was prescribed Hydrocodone-Acetaminophen 10-325 MG tablets, 1 tablet by mouth every 6 hours for pain, on [DATE]. Record review of the facility's Provider Investigation Report, dated [DATE], reflected on [DATE] between 7:00PM and 10:00PM 44 Hydrocodone-Acetaminophen 10-325 MG tablets prescribed to Resident #1 were reported missing from a nurse's medication cart. Medication Aide A, who had access to the cart between 7 PM and 10 PM claimed she was unaware of the Hydrocodone in the cart and only administered narcotics to two other residents. Charge Nurse B confirmed the Hydrocodone was missing during her 10 PM count with Medication Aide A, while Charge Nurse B verified it was present during her 7 PM count with Medication Aide A. The discrepancy indicates the Hydrocodone disappeared between 7 PM and 10 PM, with Medication Aide A as the sole individual with access during that time. The missing count sheet further obscured the discrepancy until Charge Nurse B discovered the loss the next day. Each personnel with access to the medication cart was drug tested at the facility. Medication Aide A failed a drug test in which she tested positive for Benzodiazepine and marijuana for which she was prescribed neither. Medication A's employment with the facility was terminated. The police department was Page 1 of 3 675822 675822 03/26/2025 Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

F 0755 notified, and a report was filed for the missing Hydrocodone-Acetaminophen. Level of Harm - Minimal harm or potential for actual harm Record review of Facility staff in-service was completed on the facility's-controlled substance policy which included receiving, storing, and handling narcotic medications. A card count for all controlled substances was enforced every shift. Residents Affected - Few Record review of a pharmacy packing slip addressed to Resident #1 reflected 45 Hydrocodone-Acetaminophen tablets were delivered to the facility on [DATE]. Record review of Resident #1's Medication Administration Record show she was administered one Hydrocodone-Acetaminophen tablet on [DATE] at 1PM by Charge Nurse B. Observation of the medication cart on [DATE] at 11:40 a.m., which included a review of narcotic logs and count sheets, reflected no evidence of a current drug diversion. The facility staff were following the facility's policies and procedures to prevent a drug diversion. The observation was completed with Charge Nurse B. During a phone interview with Medication Aide A on [DATE] at 12:47 p.m., she stated the medication count was correct when she left her shift at 10 p.m. but admitted she was not paying full attention when counting with the nurse. She insisted the numbers matched in the book and pill count but could not recall details clearly. Medication Aide A stated she believed she was being set up but could not name anyone with a specific grudge against her. During an interview with the Administrator on [DATE] at 2:00 p.m., she stated the Hydrocodone-Acetaminophen arrived at the facility on [DATE] and Charge Nurse B administered one tablet to Resident #1 on [DATE] at 1 p.m. She stated that on [DATE] Charge Nurse B worked from 7 a.m. to 7 p.m. She stated the standard protocol was a nurse completed the medication counts with the medication aides. The Administrator stated that on [DATE], Charge Nurse B counted medications with Medication Aide A at 7 p.m. and all medications, including the Hydrocodone-Acetaminophen were accounted for. She stated Medication Aide A passed medications on [DATE] between 7 p.m. and 10 p.m. She stated at 10 p.m. Medication Aide A counted the medications with Nurse C. The Administrator stated that Nurse C did not count any Hydrocodone-Acetaminophen tablets because the tablets were not in the cart. She stated that Nurse C had no knowledge of the Hydrocodone-Acetaminophen being prescribed to Resident #1 prior to her shift. She stated if the Hydrocodone-Acetaminophen and count sheet were in the cart as they should have been, Nurse C would have counted them. She stated everything else Nurse C counted was accurate. The administrator stated Medication Aide A's drug test was positive and she was terminated due to her results, and she reported Medication Aide A to the state survey agency. She stated the facility never recovered the missing Hydrocodone-Acetaminophen tablets. The Administrator stated Resident #1's hospice was notified about the missing Hydrocodone-Acetaminophen. She stated hospice directed the facility to administer Morphine for pain management. Resident #1 was deceased at time of the survey, therefore surveyor was unable to interview Resident #1. Review of the facility's Controlled Substances Policy, dated 12/2024, reflected, .All controlled medications will be stored under double lock and checked for accountability at each change of shift by the nurse going off duty and the nurse coming on duty. Documentation of the audit will be completed on the appropriate form Entries are to be made in pen each time a controlled substance is used. The 675822 Page 2 of 3 675822 03/26/2025 Beltline Healthcare Center 106 N Beltline Rd Garland, TX 75040

F 0755 Level of Harm - Minimal harm or potential for actual harm nurse administering the medication will record the following information: Date and time drug is administered, amount of drug administered, remaining balance of drug, and signature of nurse administering drug. If the pharmacy does not provide a controlled substance audit sheet, the nursing staff will utilize the facilities-controlled drug audit sheet and fill in all of the required information from the Rx label of the medication being audited. Residents Affected - Few 675822 Page 3 of 3