Inspection·December 9, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few doing what everyone else was when it came to counting the narcotics. She said she did not think it was the right way to do it. She said the accuracy of narcotic counts was important because it was something that could go missing, and the residents might not get their pain controlled. She said she did not know why she never brought it up (the way the narcotics were counted) to anyone.Observation and interview with Resident #1 on 10/30/25 at 8:45 am revealed a well-kept female on oxygen. She was awake and oriented. She was on a pressure-reducing air mattress. She said the doctor changed her pain medications last week, and she was no longer taking the liquid morphine every 2 hours, but now an extended-release morphine pill every 12 hours, and was due at 9:00 am. She said those were not working very well. She said she also got oxycodone scheduled every 6 hours and had a fentanyl patch. (100mcg). She said her pain scale right now was a 7 or 8 (up from her usual 5). She said she was on hospice, and they came in three times a week for showers. She said she tolerated her showers without her oxygen. She said she was on hospice and took strong pain medication because she had a groin wound from cancer. She said her pain was not out of control, but she wished she could have the liquid morphine again because it worked well for her. In an interview with the DON and DR on 10/30/25 at 8:55 am regarding the resident's pain level. The DR said to the DON to get her on whatever works best for her without knocking her out. He said the fentanyl was not really working for her. He said he did not know how she was still alive with that horrible wound she has. The DON said they were getting the liquid morphine in 120ml vials, and the missing 5 ml's was so random and everyone freaked out over it, meaning it was difficult to think about a nurse stealing morphine from a hospice patient. Interview and record review with the DON on 10/30/25 at 10:05 am, the Narcotic count sheet dated 10/15/25-10/19/25 revealed a count of 11 ml's on 10/19/25 at 4:15 am by LVN B. At 4:30 am, the count was 10 ml by LVN A. She said LVN A was not in the building at 4:30 am because she worked the 6 am- 10 pm shift. The next entry was at 6:30 am on 10/19/25, signed by LVN C for 1 ml, and the count showed 4 ml. Then 3 ml at 10:00 am, 2 ml at 1:00 pm, 1 ml at 4:00 pm, and 0 ml at 9:15 am. She said an empty bottle of morphine was found (by unknown) in a trash can at the nurse's station on 10/19/25, and assumed it was the one referred to on the narcotic count sheet signed by LVN A. She said the empty bottle was not retrieved. She said it was against the policy to throw empty bottles or medication cards of narcotics in the trash. She said they had to go into the destruction bin. Record review of Resident #1's Individual Control Drug Record for Morphine 100mg/5ml Give 0.25 to 1 ml PO (by mouth) Q (every) 2hrs for pain/SOB (shortness of breath) Rx #2057026 Date Dispensed 08/25/25 revealed on 10/19/25, LVN A administered 1 ml to Resident #1 at 4:30 am, 6:30 am, 10:00 am, 1:00 pm, 4:00 pm and 9:15 pm. Record review of LVN A's time sheet revealed on 10/19/25, she clocked in at 5:47 am and clocked out at 10:02 pm. Record review of Resident #1's MAR for October 2025 revealed on 10/19/25 at 4:15 am, LVN C administered 1 ml of liquid morphine, and the remaining count was 11 ml. At 6:15 am, 10:00 am, 1:38 pm, and 9:35 pm, LVN A administered 1 ml of liquid morphine, and the remaining count was 1 ml. At 11:41 pm, LVN C administered 1 ml of liquid morphine to Resident #1, and the remaining count was 0 ml remaining.Record review of the DON's interview with LVN A dated 10/20/25 revealed she did not know why she would have signed out a dose of medication at 4:40 am when she was not in the building, she did not know and could not explain why the liquid morphine for Resident #1 went from 10 ml's to 4 ml's, and stated she did give medications that were not documented and she frequently signed out medications on the narcotic count sheet and not in the electronic health record. She was aware of the policy because she had been counseled before for not immediately charting when giving narcotics. She did not know why she did not report a possible drug diversion, but left the building after her shift. Record review of LVN B's written and signed statement dated 10/19/25 at 9:55 pm, she stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675892 If continuation sheet Page 2 of 4 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 675892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Pointe Plaza 1008 Enterprise Blvd Rockport, TX 78382 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few counted narcotics with LVN A on the 400 hall, who told her Resident #1 was out of liquid morphine and hospice had been called and could not deliver any more until 10/20/25. LVN A also told her she obtained a one-time dose of oxycodone if needed through the night while waiting for the morphine. LVN B stated she realized Resident #1 had 11 ml's left in the bottle when she left from her previous shift the night before, and Resident #1 should have had at least 3 or more doses left. At this point, the DON was notified, and an empty liquid morphine bottle was found in a trash can on the 400 hall. Record review of LVN F's handwritten and signed statement dated 10/20/25 revealed she and LVN B had been discussing erratic behaviors of LVN A, in that she had allowed a hospice patient (Resident #1) to run out of morphine before she called for a refill. She wrote, she and LVN B double checked the narcotic sign out sheets and noticed the liquid morphine for Resident #1 had gone from 10 ml to 4 ml, and LVN B found an empty bottle of liquid morphine in the 400 hall trash can. The DON was notified at this time. LVN's A, C, and F were not available for interview after multiple attempts beginning on 10/30/25 at 9:00 am to 5:30 pm. Messages and a callback number were left. LVN B was unavailable for interview due to she was out of the country on a cruise.In an interview with LVN D on 10/30/25 at 2:42 pm, she said she did not know what happened when she wrote in 39 ml instead of 49 ml on the narcotic drug count sheet dated 10/03/25 at 6:45 am. She said 10 ml missing was a lot of morphine to be missing. She said she could not explain it. She said the process was to pay better attention and make sure they (nurses) were reading the bottle right. She said LVN C was the name on the narcotic shift count sheet prior to hers when the mistake was made. She said she could not explain why the count sheet was timed at 6:45 am, then again at 6:45 am when 10:15 am was written in, crossed out, written again, along with 6:45 on 10/03/25. She said her urine sample was not going to be positive. She said they (herself and LVN C) should have looked at the bottle and read the label before they counted at shift change. She said she should have looked at the syringe closer when she drew it up. She said narcotic sheets and counts were important because that was how they knew if something was missing. She said morphine belonged to the patients. She said the nurses had in-services on narcotics, but did not know when the last time was. Then she said the last one was about 2 weeks ago, that covered the right count on the carts, right patient, right dose, right amount in the bottle. She said the nurses were not provided with a policy at the in-service. She said if she found a discrepancy, she would take it to the DON immediately. She said she had never found a discrepancy here or ever, that she could recall. She said she did not know how someone could take a resident's pain medication. She said the facility had enough checks and balances for this not to happen. She said she was afraid she was going to lose her job, and she had been a nurse for 35 years. In an interview with the DON on 10/30/25 at 5:30 pm, she said the process for counting narcotics was for the nurses to count at the beginning and end of every shift, and if a nurse had to leave the floor or building. She said if there was a discrepancy identified and the nurses were unable to reconcile the count sheet, they were to stop, not sign the sheets, and notify the DON. She said she was responsible for accurate narcotic counts, as well as destruction. She said she would investigate the situation, such as if something was missed or overlooked. She said if she could not resolve the issue, the ADM would be notified, and an investigation would ensue. She said for any narcotic discrepancy, nurses would be drug tested on the spot if they were still in the building, and as soon as they could be reached otherwise. She said all staff in-services were and would be conducted. She said monitoring the actual counts of the narcotics and audits were and would be done for all carts and possibly an ad hoc QAPI. She said the individual control drug record sheet headings were missing information such as quantity received, or physician name, the Rx number, or the date dispensed. She said there was nowhere to initial the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675892 If continuation sheet Page 3 of 4 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 675892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulf Pointe Plaza 1008 Enterprise Blvd Rockport, TX 78382 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete headings, and she was going to change that. She said it would be harmful to residents if their pain control were inadequate because of misappropriation of their narcotics. She said LVN's A, B, C, D, E, and F were all drug tested and all were negative. Interview with the ADM on 10/30/2025 at 5:45 pm, he said the DON was responsible for the nurses, and he became involved when the situation with narcotics could not be rectified. He said LVN A was drug tested, and the results were negative, but she was terminated because she had violated several policies. He said the DON found several instances where LVN A's times on Resident #1's MAR did not match her times of administration on the individual control drug record, where the morphine was actually counted. He said LVN A was terminated on 10/20/25.Record review of LVN A's personnel file revealed a medication discrepancy report for LVN A dated 10/18/25-10/19/25 for Morphine 100mg/5ml given x4 over 2 days and not documented in Resident #1's electronic chart. 5ml of Morphine was not accounted for. LVN A was written up, counseled, and suspended. A medication discrepancy report for LVN A dated 10/20/25 for violation dates 10/18/25 and 10/19/25 revealed the nurse gave morphine to Resident #1, documented on the narcotic sheet but did not document in the electronic health record on 10/18/25 x2 and 10/19/25 x2. LVN A did not report a potential drug diversion. LVN A declined to give a statement. LVN A was suspended pending investigation. The report was signed by LVN A. LVN A was terminated on 10/20/25. Record review of a liquid morphine audit dated 10/21/25 for the six residents prescribed liquid morphine revealed that only Resident #1 had a discrepancy. Record review of all medication cart audits dated 10/20/25 revealed no discrepancies with all narcotics. Record review of all narcotic count sheets checked for anomalies dated 10/21/25, 10/22/25, and 10/23/25 revealed no anomalies. Record review of all staff in-services dated 10/20/25-Abuse and Neglect, Drug Diversion, accurate shift counts, patterns of residents who only have pain complaints on a certain shift or with a certain staff member, complaints of increased pain at the start of a shift with documentation of pain medication administered at the end of the previous shift, multiple errors/disposed of meds on narcotic sign out sheet, be aware of suspicious activity, behavior, or impairment, report immediately, Always do a narcotic count at shift change, count all meds in the narc box every time, verify all items-do not assume the count is correct, once you sign off for that cart, you are responsible, make sure no signatures, dates, or times are missing. Record review of the facility policy dated April 2007, titled Controlled Substances, stated, The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. 4. If the count is correct, a control sheet must be made for each substance. Do not enter more than one prescription per page. This record must contain c. Quantity received, h. date and time received. i. time of administration. Event ID: Facility ID: 675892 If continuation sheet Page 4 of 4