Health inspection·April 14, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 ensure assessments accurately reflected the resident's status for one (Resident #1) of nine residents reviewed for comprehensive assessment accuracy. Residents Affected - Few The facility failed to ensure Resident #1 was assessed for pressure ulcers/injuries. The facility failure could place residents at risk of inaccurate assessments and not having their needs met. Findings included: Review of Resident #1's quarterly MDS assessment, dated 04/04/23, revealed she was an [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses were hypertension, diabetes mellitus, hyperlipidemia, aphasia, cerebrovascular accident, Non-Alzheimer's Dementia, seizure disorder, anxiety disorder, depression, psychotic disorder, and polyarthritis. She had clear speech and was usually understood and usually understood others. She had a BIMS score of 2 which indicated severe cognitive impairment. Section M0300- Current number of unhealed pressure ulcers/injuries at each stage of the resident MDS assessment reflected she had 1 stage 3 pressure ulcer. Section M1200- Skin and ulcer/injury treatments of the resident MDS assessment reflected she received pressure ulcer/injury care. In an observation and interview of Resident #1 on 04/13/23 at 10:15 AM revealed she did not have any pressure ulcers/injuries. She stated she did not have any wounds. She refused a skin assessment. Observation of her arms and heels revealed there were no skin issues. Review of Resident #1's physician orders, dated 04/14/23, reflected left wrist: cleanse area with normal saline/wound cleanser, pat dry, apply TAO and dry dressing daily, every day shift for wound care (start date 01/28/23). Review of facility weekly pressure ulcer report, dated 3/28/23, revealed Resident #1 did not have any pressure ulcers/injuries (written by the ADON). Review of facility wound care physician notes, dated April 2023, revealed Resident #1 did not have any pressure ulcers/injuries Review of Resident #1's Care Plan, undated, reflected her focus was documented pressure ulcer. Her goals were wound will show signs of improvement, management of pressure ulcer, and prevention of future pressure ulcers. Her interventions were complete mini nutritional evaluation, educate Page 1 of 13 675870 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident/representative about proper skin care to prevent skin breakdown, educate resident/representative on importance of keeping skin clean and moisturized, encourage resident to frequently shift weight, encourage the use of lifting devices while in bed, evaluate skin for areas of blanching or redness, evaluate ulcer characteristics, and if drainage present, obtain order for culture, keep skin clean and well lubricated, monitor bony prominences for redness, monitor nutritional status, monitor ulcer for signs of progression or declination, notify family of new onset finding, notify provider if no signs of improvement on current wound regimen, provide skin care per facility guidelines and PRN as needed, provide wound car per treatment order, and refer to specialized practitioner for wound management. Interview with the MDS Coordinator on 04/14/23 at 12:09PM revealed her position was responsible for completing the MDS assessments but the DON was responsible to sign off on them as accurate. She stated at the time of the quarterly MDS assessment Resident #1 had a stage 3 pressure ulcer. She stated the purpose of a MDS assessment was to show a picture of the resident and what was going on with the resident. She stated the importance of MDS assessment accuracy was to show progress or decline regarding the resident's care. She stated she communicated with the ADON regarding Resident #1's wound care, reviewed physician orders, and reviewed physician notes. She stated she did not communicate or assess Resident #1 prior to completing her quarterly MDS assessment. She stated she was unaware the resident had not had a stage 3 pressure ulcer/injury. She stated if the information she gathered to complete the MDS was inaccurate it could cause the MDS assessment to be inaccurate and cause Resident #1 to receive inadequate care. Interview with the Administrator on 04/14/23 at 4:55 PM revealed the facility did not have a policy regarding MDS inaccuracies. He stated the facility followed the RAI regarding MDS assessments. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1, dated October 2019, reflected, 1.3 Completion of the RAI: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. 675870 Page 2 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (resident#1) of 9 residents reviewed for ADLs. Residents Affected - Few The facility failed to provide showers consistently for Resident #1. This failure placed residents at risk for poor personal hygiene, odors, and a decline in their quality of life. Findings included: Review of Resident #1's quarterly MDS assessment, dated 04/04/23, revealed she was an [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses were hypertension, diabetes mellitus, hyperlipidemia, aphasia, cerebrovascular accident, Non-Alzheimer's Dementia, seizure disorder, anxiety disorder, depression, psychotic disorder, and polyarthritis. She had clear speech and was usually understood and usually understood others. She had a BIMS score of 2 which indicated severe cognitive impairment. Her Functional Status section indicated her self-performance was total dependence and she needed one-person physical assistance with bathing . Review of Resident #1's Care Plan, undated, reflected her focus was an ADL self-care performance deficit due to diagnoses of dementia, musculoskeletal impairment, confusion, and impaired balance. Her goals were to maintain current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene through review date. Her interventions were bathing; she was totally dependent on staff to provide a bath three times a week and as necessary. In an observation and interview of Resident #1 on 04/13/23 at 10:15 AM revealed she had brown discoloration and dead skin between her toes. She stated she needed assistance with showers. She stated she did not remember her exact shower days and did not remember the last time she received a shower. Review of the facility's shower binder on 04/13/23 revealed Resident #1 did not have any shower sheets. Review of Resident #1's ADL verification dated 04/13/23 revealed she had not consistently received showers from 04/01/23 to 04/13/23. She received a shower on 04/01/23, 04/06/23, and 04/08/23. Interview with LVN A on 04/13/23 at 2:50 PM revealed Resident #1 had dead skin and moisture between her toes. She stated Resident #1's shower schedule was Tuesday, Thursday, and Saturday. She stated the CNAs were responsible for showering the residents. She stated the last time Resident #1 received a shower was 04/08/23 per her EMR. She stated she was unable to locate Resident #1's shower sheets. Interview with CNA C on 04/14/23 at 9:30 AM revealed Resident #1 was bathed the morning of 04/13/23. She stated she did not know why her shower was not documented. She stated showers are documented in the residents' EMR and shower sheets. She stated she cleaned between Resident #1's toes. She stated the discoloration and dead skin between Resident #1's toes might have reappeared after being bathed on 04/13/23. She stated the purpose of ensuring residents were bathed was to reduce the risk of 675870 Page 3 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0677 skin breakdown, wounds, and rashes. Level of Harm - Minimal harm or potential for actual harm Interview with the ADON on 04/14/23 at 3:48 PM revealed Resident #1's shower days were Tuesdays, Thursdays, and Saturdays. She stated Resident #1 had received her showers as scheduled. She stated the last documented shower was 04/08/23. She stated the resident was bathed in the afternoon of 04/13/23. She stated Resident #1's showers were not consistently documented and could not confirm the showers were completed. She stated her expectation was for staff to provide residents showers as scheduled. She stated staff were responsible for cleaning between resident toes during showers. She stated staff were supposed to document bathing in Resident #1's EMR and complete shower sheets. She stated she should check EMR and residents more often to ensure baths were provided. She stated the purpose of bathing residents was to prevent skin issues and to maintain resident wellbeing. Residents Affected - Few Review of facility policy titled, Policy & Procedure: Bathing and Hair Care, undated, reflected The facility strives to ensure that a resident/patient entering the facility will maintain the same personal hygiene habits that they held while in the community. 675870 Page 4 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 a resident at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of four residents reviewed for pressure ulcers. Residents Affected - Few The facility failed to ensure Resident #1 was wearing heel protectors while in her Geri-chair. This failure could place residents at risk for pressure ulcers/injuries. Findings included: Review of Resident #1's quarterly MDS assessment, dated 04/04/23, revealed she was an [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses were hypertension, diabetes mellitus, hyperlipidemia, aphasia, cerebrovascular accident, Non-Alzheimer's Dementia, seizure disorder, anxiety disorder, depression, psychotic disorder, and polyarthritis. She had clear speech and was usually understood and usually understood others. She had a BIMS score of 2 which indicated severe cognitive impairment. Her Functional Status section revealed she required one-person physical assist with bed mobility, dressing, eating, toilet use, personal hygiene, and locomotion on/off unit. She required two-person assist with transfers. Her Skin Conditions section revealed she was at risk of developing pressure ulcer/injuries. Review of Resident #1's Care Plan, undated, reflected her focus was documented pressure ulcer. Her goals were wound will show signs of improvement, management of pressure ulcer, and prevention of future pressure ulcers. Her interventions were complete mini nutritional evaluation, educate resident/representative about proper skin care to prevent skin breakdown, educate resident/representative on importance of keeping skin clean and moisturized, encourage resident to frequently shift weight, encourage the use of lifting devices while in bed, evaluate skin for areas of blanching or redness, evaluate ulcer characteristics, and if drainage present, obtain order for culture, keep skin clean and well lubricated, monitor bony prominences for redness, monitor nutritional status, monitor ulcer for signs of progression or declination, notify family of new onset finding, notify provider if no signs of improvement on current wound regimen, provide skin care per facility guidelines and PRN as needed, provide wound car per treatment order, and refer to specialized practitioner for wound management. Review of Resident #1's physician orders, dated 05/09/22, reflected Remove hell heel protector boots and monitor skin integrity. Bilateral heel protector boots while up in Geri chair. Off at night. Observation and interview with Resident #1 on 04/13/23 at 10:50 AM revealed she was in a Geri chair with her legs elevated without heel protective boots. Resident #1 stated she did not know why she was not wearing heel protective boots. There were no skin issues noticed on her heels. In an interview with LVN A on 04/14/23 at 10:15 AM revealed Resident #1 was supposed to wear heel protective boots while in the Geri chair. She stated she was unaware Resident #1 was not wearing heel protective boots. She stated CNAs were responsible for putting the boots on Resident #1 when she was in her gerichair. She stated the heel heal protective boots were a preventative measure for Resident #1. She stated the purpose of the boots were to relieve pressure and to prevent pressure sores. 675870 Page 5 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0686 She stated Resident #1 not wearing the boots as ordered could put her at risk of pressures sores. Level of Harm - Minimal harm or potential for actual harm In an interview with the ADON on 04/14/23 at 3:48 PM revealed she was unaware Resident #1 was not wearing her heel protective boots. She stated the boots helped prevent heel problems and protected Resident #1's heels while in the Geri chair. She stated Resident #1's EMR informed staff when the protective heel boots were to be worn. She stated Resident #1 was at risk for pressure injuries/ skin issues due to her Geri chair being hard, and boots not being worn. She stated her expectation was for staff to put boots on residents as ordered. Residents Affected - Few Review of the facility policy titled, Prevention of Pressure Ulcers/Injuries, revised date December 2022, reflected The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. 675870 Page 6 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one (Resident #2) of three residents observed for indwelling urinary catheters. The facility failed to ensure Resident #2's catheter bag was not on the floor. These failures could place residents with urinary catheters at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Review of Resident #2's Quarterly MDS assessment, dated 04/04/23, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He had no speech, was rarely/never understood by others, and rarely/never understood others. His BIMS revealed he was rarely /never understood. His cognitive pattern revealed he had an altered level of consciousness that comes and goes, changes in severity. His diagnoses included: anemia, hypertension, neurogenic bladder, diabetes mellitus, hyponatremia, aphasia, Non-Alzheimer's dementia, seizure disorder, anxiety disorder, and respiratory failure. His appliances used was an indwelling catheter and he was always incontinent. Review of Resident #2's physician orders, dated 04/14/23, reflected, Foley Catheter 18F with 10ml balloon diagnosis for Foley Catheter use; Neurogenic Bladder (start date 09/21/22). Review of Resident #2's care plan, undated, reflected his focus was an indwelling catheter due to diagnosis of neuromuscular dysfunctional of bladder. 18fr, 10ml balloon. Change PRN. His goal was to remain free from catheter related trauma through the next review date and show no signs/symptoms of urinary infection through the next review date. His intervention was nurses will monitor resident on routine rounds to ensure residents with indwelling catheters have securement devices in place, to prevent pain, discomfort, UTIs, dislodgement, and urethral trauma. An observation and attempted interview with Resident #2 on 04/13/23 at 11:10 AM revealed his catheter bag was clipped to his bed and laying on the floor. His bed was positioned low to the floor. Resident #2 was unable to communicate. An interview with CNA C on 04/14/23 at 9:13 AM revealed Resident #2 had a foley catheter. She stated she was assigned to Resident #2. She stated his catheter bag was supposed to be clipped to his bed and covered with a privacy bag. She stated the privacy bag was used to keep Resident #2's catheter bag from being on the floor. She stated CNAs and nurses were responsible for ensuring Resident #2's catheter bag was not on the floor. She stated she would notify the nurse if she observed Resident #2's uncovered catheter bag on laying on the floor. She stated his catheter bag being on the floor was an infection control issue. An interview with LVN A on 04/14/23 at 10:09 AM revealed Resident #2 had a foley catheter. She stated she noticed his catheter bag was on the floor on 04/13/23 during surveyor observation. She stated she placed the catheter bag inside a privacy bag to prevent the bag from touching the floor. She stated the CNAs were responsible for ensuring Resident #2's catheter bag was not on the floor. She 675870 Page 7 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she rounds behind the CNAs to ensure catheter bag placement. She stated his catheter bag being on the floor was an infection control issue. An interview with the ADON on 04/14/23 at 3:48 PM revealed Resident #2 had a catheter. She stated his catheter bag should not have been on the floor. She stated his bed was kept at the lowest position to the floor and caused his catheter to touch the floor. She stated she had informed staff to use privacy bags to prevent his catheter bag from touching the floor. She stated she monitors staff by making rounds throughout the day. She stated she placed a wash basin under his catheter bag on 04/14/23 to prevent the catheter bag from touching the floor. She stated he was at risk of infection due to the catheter bag being on the floor. She stated she was not made aware of his catheter bag being on the floor until surveyor observation. Review of facility policy, Catheter Care, Urinary, dated December 2022, reflected: The purpose of this procedure is to prevent catheter-associated urinary tract infections. 675870 Page 8 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities for one (Resident #2) of three residents reviewed for enteral nutrition. 1. The facility failed to ensure Resident #2's feeding machine was in good repair. 2. The facility failed to ensure Resident #2's head of the bed was elevated 30 to 45 degrees during his continuous feeding. These failures could place residents on enteral feeding at risk for not receiving appropriate enteral feeding and treatment services. Findings included: Review of Resident #2's Quarterly MDS assessment, dated 04/04/23, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. He had no speech, was rarely/never understood by others, and rarely/never understood others. His BIMS revealed he was rarely /never understood. His cognitive pattern revealed he had an altered level of consciousness that comes and goes, changes in severity. His diagnoses included: anemia, hypertension, neurogenic bladder, diabetes mellitus, hyponatremia, aphasia, Non-Alzheimer's dementia, seizure disorder, anxiety disorder, and respiratory failure. Her nutritional approach was a feeding tube. Her proportion of total calories received through parenteral or tube feeding was 51% or more. Her average fluid intake per day by IV or tube feeding was 501 cc/day or more. Review of Resident #2's care plan, undated, reflected Required tube feeding due to swallowing problem and on Diabetic Source AC at 80ml/hr for hours via pump and on 30 ml of water flush every 6 hours via dual pump may be off 1 hour for ADLs. Will be free of aspiration through next review date. Will maintain adequate nutritional and hydration status aeb weight stable, no signs/symptoms of malnutrition or dehydration through the next review date. Monitor/document/report to MD PRN: aspiration, fever, SOB, tube dislodged, infection at tube site, self-extubating, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abnormal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, and dehydration. Resident needs the head of bed elevated 45 degrees during and thirty minutes after tube feed. Review of Resident #2's physician's order, dated 04/14/23, reflected Enteral feed order, every shift ensure HOB elevated 30-45 degrees every shift (start date 10/25/21). Review of Resident #2's physician's order, dated 01/10/23, reflected Enteral feed order, every shift enteral feeding Diabetic Source AC at 80 CC/HR via dual pump for 23 hours (start date 02/01/22). 675870 Page 9 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an observation and interview of Resident #2 on 04/13/23 at 11:10 AM revealed his bed was flat and at the lowest position to the floor while receiving a g-tube feeding. His feeding machine was beeping and displayed error. The resident appeared to be agitated and restless. There were no nurses or CNAs observed on the resident's hall. The nurse's station was located near the beginning of the hall and Resident #2's room was located at the end of the hall. Resident #2 did not have a roommate. The beeping from his feeding pump could not be heard from the nurse's station. The surveyor notified the ADON and LVN A Resident #2's feeding pump was beeping and displayed error. The ADON and LVN A entered his room at 11:17 AM. The ADON raised his bed to a high position from the floor and pushed the hold button on the feeding machine. The feeding machine stopped beeping and no longer read error. The feeding pump machine displayed his feeding rate. The bed remained in a flat position while the ADON and LVN A repositioned Resident #2 in bed during his feeding. After he was repositioned the ADON raised the head of the bed to a 30 - 45 degree angle. The resident appeared to be calmer after the ADON raised the head of his bed, repositioned him, and fixed his feeding machine. The resident was unable to communicate. In an interview with LVN A on 04/14/23 at 1:56 PM revealed Resident #2 was unable to verbalize his needs. She stated he had a g-tube and received continuous feeds. She stated she was unaware his bed was flat, feeding machine was beeping, and the feeding pump displayed error. She stated his room was located at the end of the hall and she did not hear his feeding pump beeping because she was not on the hall. She stated his feeding machine was not supposed to read error. She stated the feeding machine beeps if there was a hold or there was an error. She stated she was unaware his bed was flat while he was receiving continuous feeds. She stated his bed was not supposed to be flat during tube feedings. She stated Resident #2's head of bed should have been at a 45 degree angle. She stated he could have aspirated or formula could travel where it's not supposed to be. She stated she frequently rounded on residents but was assigned three halls on 04/13/23. She stated she last rounded on Resident #2 during his medication administration. She stated he was left with his head of bed at a 45 degree angle and his feeding machine was working. She stated she did not know how his bed ended up flat or the machine reading error. She stated he was not physically capable of moving the bed or touching the feeding pump machine. She stated she went into his room and corrected the issue after surveyor notification. She stated the feeding pump machine was on hold. She stated she did not know if the resident received the amount of formula as ordered by the physician. She stated Resident #2 was at risk of not receiving enough nutrients and formula due to his feeding pump not functioning. She stated she helped the ADON reposition him in bed and raised the head of bed to a 45 degree angle. She stated he did not need to be assessed. In an interview with the DON on 04/14/23 at 03:48PM revealed Resident #2 had a g-tube and received continuous feeds. She stated his head of bed was to be raised at a 30 to 45 degree angle and was not to be flat. She stated the head of the bed was to be raised to prevent aspiration and pneumonia. She stated she was not aware the resident's bed was flat and his feeding pump was malfunctioning until informed by the surveyor. She stated maybe a CNA laid him flat to provide incontinent care and forget to restart the feeding machine and reposition the bed. She stated she will be re-educating staff. She stated the feeding pump machine said error if the machine was on hold. She stated she had to push run and the machine was working. She stated there were no reasons the staff did not respond to his feeding pump machine. She stated he received the amount of formula as ordered. She stated Resident #2 was not affected by the feeding machine error. She stated there could be a potential risk if the nurse had not gone back to fix the machine such as dehydration, weight loss, and nutrition loss. Review of the facility policy, Enteral Nutrition, dated December 2022, reflected Adequate nutritional support through enteral feeding 675870 Page 10 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0693 will be provided to residents as ordered. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675870 Page 11 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observations, interview, and record review, the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs, to meet the needs of each resident, for one (Resident #3) of four residents reviewed for medication storage. The facility failed to ensure Resident #3's medications were secured inside of the medication cart on 04/13/23. This failure could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion. Findings included: Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed she was an [AGE] year-old female who was admitted to the facility 12/31/20. Her diagnosis included: anemia, hypertension, diabetes mellitus, hyperlipidemia, cerebrovascular accident, and hemiplegia. She was understood, understood others, and had clear speech. Her BIMS revealed a BIMS should not be conducted because she was rarely /never understood. There was no evidence of delirium or psychotic behaviors. Review of Resident #3's physician orders dated 04/14/23 reflected the following medications: -Ascorbic acid tablet 500 mg give 1 tablet via g-tube one time a day for supplements -D-Mannose capsule 1000 mg give 1 capsule by mouth two times a day for supplements - Lasix 40 mg tablet give 1 tablet via g-tube one time a day for hypertension - metoprolol 25 mg tablet give 1 tablet via g-tube two times a day for blood pressure -Aspirin chewable tablet 81 give 1 tablet via g-tube one time a day for cerebral infraction -MethiMazole tablet 5 mg give 1 tablet via g-tube in the morning for low TSH -Plavix 75 mg tablet give 1 tablet via g-tube one time a day for cerebral infraction Review of Resident #1's MAR dated 04/01/23 to 04/30/23 reflected the resident was given the following medication by LVN B on 04/13/23: -Ascorbic acid tablet 500 mg scheduled for 8:00 AM -D-Mannose capsule 1000 mg scheduled for 8:00 AM - Lasix 40 mg tablet scheduled for 8:00 AM 675870 Page 12 of 13 675870 04/14/2023 Lindan Park Care Center LP 1510 N Plano Rd Richardson, TX 75081

F 0761 - metoprolol 25 mg scheduled for 8:00 AM Level of Harm - Minimal harm or potential for actual harm -Aspirin chewable tablet 81 scheduled for 8:00 AM -MethiMazole tablet 5 mg scheduled for 8:00 AM Residents Affected - Few -Plavix 75 mg tablet scheduled for 8:00 AM In an observation on 4/13/23 between 8:24 AM and 8:30 AM revealed there were 7 different pills in a plastic medication cup on top of the medication cart located in a hall. There were no staff in the hallway supervising the medication. In an interview with LVN B on 04/13/23 at 8:30 AM revealed he had dispensed Resident #3's medication into a medication cup and left them on top of the medication cart. He stated he had to provide care to another resident and forgot to place the medications back into the locked medication cart. He stated he did not administer the medications to Resident #3 before providing care to the other resident. He stated the risks to improper medication storage was residents could get the wrong medication. Interview with the ADON on 04/14/23 at 3:48 PM, revealed Resident #3's medications were not to be left on top of the medication cart unsupervised. She stated LVN B should have stored the medication cart and locked the cart. She stated she ensured proper mediation storage by observing staff and checking medication carts. She stated there was a risk of someone else taking Resident #3's medication. Review of the facility policy, Storage of Medication, dated December 2022, reflected Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall only be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 675870 Page 13 of 13