Health inspection·September 27, 2023

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. Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments on 1 of 5 medication carts reviewed for storage of drugs. Nurses' Medication Cart was left unattended, unlocked and medication cart keys left in medication cart lock by nurse's station area. This deficient practice could affect residents who have medications on the Nurses' Medication Cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. Findings included: Observation on 09/25/23 at 1:45 PM revealed a medication cart was left unlocked, unattended and medication cart keys left in medication cart lock by nurse's station. There was one resident about 5 to 10 feet away from cart and one nurse located at the nurses station out of view of the unlocked medication cart. This surveyor opened the top drawer recognizing the cart being unlocked. Multiple medications in bulk bottles and blister packs were easily assessable for removable. The DON walked by approximately 5 to 10 minutes later and was made aware of the situation and paged RN A over the intercom to come to the nurse's station. When RN A came out of resident's room, he took ownership of the medication cart and acknowledged it being unlocked and unattended. Interview on 9/25/2023 at 3:20 PM with DON stated, medication carts should be locked at all times and RN A must have gotten distracted from locking it. DON stated it was important to keep medication cart locked at all times due to anyone being able to open it and get medications not prescribed to them. DON stated that the keys to medication carts should always be with the nurse responsible for that medication cart and in-servicing on unlocked medication carts would began immediately. Interview on 09/27/2023 at 2:00 PM., with RN A stated it was a rare circumstance to leave medication cart unlocked with keys left in it. RN A stated he was called to change a resident and was in a hurry. RN A stated it was important to not leave the keys on the medication cart because of the different types of medication including narcotics it stores and could be a safety issue. RN A stated if the keys are left on the medication cart a myriad of things could happen for example, a resident, visitor, or staff member can gain access to the meds in the cart. Record review of the Facility's Medication Carts and Supplies for Administering Medication policy and procedure states; Page 1 of 4 675892 675892 09/27/2023 Gulf Pointe Plaza 1008 Enterprise Blvd Rockport, TX 78382

F 0761 #1. The Medication cart is locked at all times when not in use. Level of Harm - Minimal harm or potential for actual harm #2. Do not leave the medication cart unlocked or unattended in the resident care areas. Residents Affected - Few 675892 Page 2 of 4 675892 09/27/2023 Gulf Pointe Plaza 1008 Enterprise Blvd Rockport, TX 78382

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread for the facility reviewed for infection control. Residents Affected - Some The facility failed to have a system in place for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread. This deficient practice place the facility residents at risk for airborne infections. The findings included: An interview on 09/27/23 at 10:28 AM with the Maintenance Director revealed he did not know what Legionnaire's was. He stated he had been working at this facility for three and a half years. The Maintenance Director stated the facility water is on city water and that he visually inspects water. The Maintenance Director stated to his knowledge, there was no system to monitor effectiveness of control measures. He stated that he had no training upon hire. He was also unaware of the facility policy, Legionella Water Management Program. An interview on 09/27/23 at 10:45 AM with Infectious Preventionist DON revealed there have not been any cases of residents with Legionellosis. An interview on 9/27/23 at 1:20 PM with the Administrator, stated there was no system in place to measure testing protocols or to intervene when control limits were not met. He stated that he was waiting on corporate to set up meeting to find out what they will be implementing regarding Legionella. Administrator was aware that the Maintenance Director was not knowledgeable about the disease Legionella. He did not have a map indicating where Legionella and other opportunistic waterborne pathogens can grow and spread. A record review of the facility's Legionella Water Management Program Policy Interpretation and Implementation revised 09/2022 indicated the water management program included the following elements: 5. b. A detailed description and diagram of the water system in the facility, including the following: 1. Receiving 2. Cold water distribution 3. Heating 4. Hot water distribution 5. Waste 5. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: storage tanks, water heaters, 675892 Page 3 of 4 675892 09/27/2023 Gulf Pointe Plaza 1008 Enterprise Blvd Rockport, TX 78382

F 0880 filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains, and medical devices such as CPAP machines, hydrotherapy equipment etc. Level of Harm - Minimal harm or potential for actual harm 5. d. The identification of situations that can lead to Legionella growth, such as: Residents Affected - Some 1. Construction 2. Water main breaks 3. Changes in municipal water quality 4. The presence of biofilm, scale, or sediments 5. Water temperature fluctuations 6. Water pressure changes 7. Water stagnation 8. Inadequate disinfection 5. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants) f. The control limits or parameters that are acceptable and that are monitored g. A diagram of where the control measures are in place h. A system to monitor control limits and the effectiveness of control measures i. A plan for when control limits are not met or not effective j. Documentation of the program 675892 Page 4 of 4