Inspection·August 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some attempted interview with Resident #2 on 08/19/25 at 3:00 p.m., Resident #2 was not interviewable. In an attempted telephone interview on 08/19/25 at 3:15 p.m., Resident #2's RP did not answer, voice message left. Record review of Resident #3's admission record dated 08/21/25 reflected an admit date of 04/28/2, an original admission date of 11/06/20, and a discharge date of 05/14/25. His relevant diagnosis included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), dementia (a group of thinking and social symptoms that interferes with daily functioning), and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions). Record review on Resident #3's significant change MDS dated , 05/15/25, reflected a BIMS score of 99, which indicated his cognition was severely altered. Record review on Resident #3's quarterly care plan dated, 04/15/25 reflected:Focus: [Resident #3] has the potential to demonstrate physical behaviors r/t made contact to throat and chest on another resident (date initiated (02/25/25). Interventions: in part included to analyzed key times, places, circumstances, triggers and de-escalate behavior and document and document and observe behavior and attempted interventions (date initiated: 03/04/25). Record review of Resident #3's Risk Management report with an effective date and time of 02/24/25 at 8:49 p.m. and authored by the DON reflected This shift resident made hand contact ot other resident throat and upper chest area. [Resident #3] noted to be getting up from wheelchair and has been walking around facility aimlessly, immediate action take: assessment, call placed to [NP] to inform of resident's status. At this time gave order for Benadryl 50 mg im x 1 dose. Call placed to [RP] to inform of his status and order.Room change, new lab orders (CBC, ammonia, vitamin D, CMP, and UA), injuries report post incident: no injuries observed post incident, Predisposing psychological factors: confused, incontinent, recent change of condition, and impaired memory. Record review of the facility's incident report dated 08/18/25 reflected:Resident-to-Resident incidents: Resident #2 and Resident #3 on 02/24/25 at 7:45 p.m. Record Review of TULIP (HHSC online incident reporting application) on 08/18/25 at 4:00 p.m. revealed a self-report by the facility's Administrator was received on 02/25/25 at 8:15 p.m. more than 24 hours after Resident #2 and Resident #3's an altercation on 02/24/25 at 7:45 p.m. The allegation was abuse. In an interview on 08/20/25 at 2:00 p.m., the DON said either the facility's Administrator or herself were responsible to ensure all allegations of abuse were reported timely. She said this incident, the Administrator was the one who reported it to the state agency. She said the incident occurred on 02/24/25 at 7:45 p.m., and it was reported to the state agency on 02/25/25 at 8:15 p.m. She said prior to May 2025, she and the Administrator thought, they had either 2 or 24 hours from when the Administrator or herself were notified of the incident. She said sometime in May 2025, they were cited for not reporting ANE allegations within the allotted timeframes. She said the surveyor who cited them educated them on the timeframes. She said Resident #2 had not sustained any injuries and Resident #3 was moved to another hall. In an interview on 08/20/25 at 2:30 p.m., the Administrator said it was her responsibility to ensure all ANE allegations were reported within the allotted timeframes to the state agency. the Administrator said the resident-to-resident altercation between Resident #2 and Resident #3 on 02/24/25 had been reported within 24 hours. 2. Record Review of TULIP (HHSC online incident reporting application) on 04/05/25 reflected an anonymous complaint with the allegation of physical environment and administration/personnel. The complainant alleged that during the week 04/07/25, a small explosion that occurred with a faulty stove in the facility's kitchen. There were no injuries to the residents or the staff. The local fire department was called. It was alleged the facility's Administrator failed to address the kitchen's faulty stove prior to the small explosion. In an interview on 08/18/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 2 of 8 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 9:30 a.m., the DM said she started working at the facility in June 2025. She said she heard that sometime in April 2025, there had been an implosion related to a hot plate left in the oven which pop and caused a loud boom effect. She said she was told after that incident; the stove was not operable. She said by the time, she was hired, there was a new stove in the kitchen. She said she was also told by her kitchen staff that the local fire department had been called and the residents in the dining room had been evacuated. She said that was all she was told about the implosion. She explained the hot plates were stainless steel plates that were heated in an oven or plate warmer and placed in an insulated dome as an underliner. The serving place was placed on top of the stainless-steel plate and covered with an insulated dome cover. The DM one of the major changes she implemented when she was hired the to no longer use hot plates to keep the resident's meals warm. In an interview on 08/18/25 at 10: 30 a.m., Maintenance Supervisor C said he had been working at the facility for one month. He said he did not know the details of what the incident with the stove was about, all he knew was that the kitchen got a new stove. In an interview on 08/18/25 at 10:15 a.m., the Dish Washer G said he had been working at the facility for the past 6 months. He said he knew the old stove had been replaced but was not sure why. He said was not working at the time of the incident. In a telephone interview on 08/18/25 at 11:00 a.m. to Maintenance Supervisor D but the phone number provided by the facility had been disconnected. In an attempted telephone interview on 08/18/25 at 11:05 a.m. and 2:15 p.m., to [NAME] I, there was no answer. In an interview on 08/18/25 at 2:41 p.m., [NAME] F. She said was one of 2 cooks in the facility and she worked the morning shift. She said the stove had been having issues with the oven and stove top. She said she had reported it to Maintenance Supervisor D on several occasions. She said prior the 04/08/25 incident, the Administrator had already purchased a new stove, but it had not arrived yet. She said the stove had two ovens, one of them would heat too much and other would not heat. She said it had to do something with the calibration. She said the silver plates were placed in the oven that would heat too much to expedite the serving process. She said whoever placed the silver plates on that side of the oven had to be vigilant because they would heat up too much. She said there were times where she would hear the silver plates cracking and that's when she knew they had been left in the oven too long. She said the afternoon cook was the one working when the incident occurred. She said when she came back the next day, she was told by the Maintenance Supervisor D to not use the stove and later that day it was taken outside. In an interview on 08/18/26 at 2:23 p.m., Dietary Aide E said only the kitchen cooks were allowed to use the stove. She said she knew there had been times in which the oven would work and then all of a sudden it didn't but did not know the specifics. She said on 04/08/25, she was scheduled with [NAME] I. She said between 6:00 and 6:30 pm (after dinner) as she was exiting the kitchen she heard a loud boom, she said at the same time she saw what she said looked like a lightening. She said she got very scared and quickly made her way to the dining room where she heard a CNA (not name given) yell fire. She said her first instinct was to transfer the few residents who were in the dining room to another hall. She said she called out for help and several staff members responded and quickly started transferring the residents away from the dining room. She said she first transferred a resident who was in a wheelchair and then a resident who was visually impaired. She said all residents were transferred to another hall. She said she was afraid for the residents. She said once she realized it was safe to reenter the kitchen, [NAME] I opened the oven door and saw a silver plate in the oven. She said the silver plate was enlarged. She said there was no smoke, no damage. She said immediately after that the stove was not used. She said what she remembered was that the residents were served sandwiches and nothing hot. She said she had been in-serviced on the topics of fire safety, food safety and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 3 of 8 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some temperature settings. In an interview on 08/18/25 at 4:20 p.m., The Administrator said that on 04/08/25 after dinner, she received a call from [NAME] I who told her that there had been a fire in the kitchen. She said she immediately asked him if the fire department had been called and he told her no. She said [NAME] I told her that it just went boom and saw a flame coming out of the oven and immediately went back in. The Administrator said [NAME] I told her the fire extinguisher was not used because the fire had immediately disappeared. She said [NAME] I told her after the boom sound and the flash, he went back into the kitchen to check for any damages and there were none. The Administrator said [NAME] I told her there was no smoke, no damage to the stove/oven, no injuries, and the flash fire had not registered with the monitoring company. The Administrator said she was told by [NAME] I the incident happened between 6:30 p.m. and 6:35 p.m. She said [NAME] I told her he had immediately shut off the gas to the kitchen. She said by the time she returned to the facility the Maintenance Supervisor H had shut off the gas to the entire building. The Administrator said she instructed Maintenance Supervisor D to call the local fire department before turning on the gas to the building. She said the fire department was called as a precaution only, she wanted to make sure there was no gas leaks. She said the fire department was called around 8:00 p.m. and after they inspected the entire building, it was deemed safe to turn on the gas back on. The Administrator said what she was told by [NAME] I was that he had accidently left a silver plate in the oven when he was cooking dinner. The Administrator said she was told (not sure by who) there were only two residents who were ambulatory in the dining room during the flash fire. She said she had not reported the incident to the state agency because it did not pose any threat to resident safety and according to the provider letter it said to not report to state emergency situations that do not pose a threat to resident health and safety secondary to proper management. She said since the cooks were having a hard time with the burners, she had already ordered a new stove prior to the incident. The Administrator provided a copy of the FD's report but stated the first sentence was not correct ( Ladder 4 responded to a report of a gas leak inside a structure), and the alarm/arrival/departure time was not correct. She said she had spoken to the FD Captain and was waiting for him to call her back to dispute the first sentence and time listed on the report. Record review on 08/19/25 at 10:00 a.m., of the local fire department incident report dated 04/08/25 reflected they had been received the call at 10:08 p.m., arrived at the facility at 10:15 p.m., and left the facility at 10:47 p.m. Under remarks it stated Ladder 4 responded to a report of a gas leak inside a structure at [facility]. We arrived at the location where we were greeted by the [Maintenance Supervisor D] with maintenance department. [Maintenance Supervisor D] stated to us that around 8:00 p.m. they had a fire in te kitchen that was not reported to us. He explained that when the worker was opening the over door, to the stove/oven, a flash fire occurs. [ Maintenance Supervisor D] secured the gas to the appliance at the stove and on the las line for the appliance. He stated that administration wanted us to check the hallway for any smell of gas in the building. We checked the hallway to the kitchen, kitchen, and dining areas. Nothing was picked up by the gas monitor.The employee was not injury and didn't seek medical attention as per [the Maintenance Supervisor D]. Record review of the facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment policy with an original date of 11/2017 and a revision date of 12/2023 reflected: Policy: It is the policy of this facility that each president has a right to be free from abuse calmly liberal, misappropriation of resident property, exploitation, and mistreatment. This includes but is not limited to freedom from, involuntary seclusion in any physical or chemical restraint not required to treat the residents and medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to facilities staff, other residents, consultants or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 4 of 8 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. If there is an allegation or suspicion reviews, the facility will make a report to the appropriate agencies as designated by state and federal laws. Procedure:In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will:Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: Note later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. No later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. Event ID: Facility ID: 675933 If continuation sheet Page 5 of 8 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 12 residents (Resident #1) reviewed for PASRR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting for Resident #1. This failure could affect residents by placing them at risk of their specialized needs not being met. Findings included: Record review of Resident #1's admission record dated 08/18/25 reflected an [AGE] year-old female admitted on [DATE]. Her relevant diagnoses included, lack of coordination, unsteadiness on feet, age-related osteoporosis (increased fracture risk due to declining bone mass and strength), and seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain). Record review of the resident's quarterly MDS assessment dated [DATE] reflected, a BIMS score of 99, which reflected her cognition was severely impaired. Further review indicated she required a wheelchair (manual or electric) for mobility. Record review of Resident #1's quarterly care plan dated 08/12/25 reflected: Focus: [Resident #1] is receiving PASRR services for IDD PASRR positive diagnosis (date initiated 07/11/25). Interventions: in part included occupational, speech, and physical therapy with long- and short-term goals. During an observation on 08/19/25 at 9:00 a.m., Resident #1 was observed sitting on her specialized wheelchair in the dining room. She was not interviewable. Record review on 08/20/25 of Resident #1's LIDDA's Individual Profile-Nursing Facility dated 01/09/25 reflected:Adaptive Aids and Medical Supplies: Due to recent falls, team agreed to specialized mattress, bolsters and concave mattress to support her from falling off the bed. An interview and observation on 08/19/25 at 9:20 a.m., MDS/RN B said she was responsible for submitting PASRR specialized services through the Simple Online Portal, but that she was not working at the facility when Resident #1 had her initial Interdisciplinary Team meeting on 01/09/25. She said the facility had 20 days to submit a completed request for nursing facility specialized services on the Simple Online Portal after the Interdisciplinary Team meeting. She was observed as she reviewed Resident #1's electronic medical record and said Resident #1's initial interdisciplinary team meeting was held on 01/09/25 and what was recommended was independent living skills training, physical therapy, occupational therapy, speech therapy, and a specialized wheelchair. She said she did not find a request for any durable medical equipment (support surface mattress). An interview on 08/19/25 at 9:45 a.m., DOR said she had been present during Resident #1's initial Interdisciplinary Team meeting held on 01/09/25. She said she remembered discussing Resident #1 required a specialized wheelchair and the possibility of a concave mattress. She said she remembered she received a call from the Administrator asking her if a specialized mattress had been ordered during the Interdisciplinary Team meeting, because she had received an email from the PASSR state office coordinator inquiring on it. She said she had told the Administrator that Resident #1 had been assessed by an Occupational Therapist and it was determined that she did not require a specialized mattress only bolsters (because she was a fall risk). Record review on 08/20/25 of Resident #1's LIDDA's Individual Profile-Nursing Facility dated 01/09/25 reflected:Adaptive Aids and Medical Supplies: Due to recent falls, team agreed to specialized mattress, bolsters and concave mattress to support her from falling off the bed. Record review on 08/20/25 of Resident #1's progress note dated 01/09/25, authored by the DOR reflected, Initial IDT meeting for [Resident #1] held with LIDDA. Resident chose not to participate in meeting. [The DOR] requested specialized wheelchair through PASRR as well as concave mattress if possible. An interview on 08/20/25 at 10:00 a.m., the DON said her involvement with PASSR was very minimum. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 6 of 8 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete said she did not know the timeframes after the IDT meeting, she said the MDS nurse in charge of that. An interview on 08/20/25 at 10:20 a.m., the Administrator said she had been present during Resident #1's initial Interdisciplinary Team meeting held on 01/09/25. She said she remembered the team had not requested a specialized mattress. She said what was requested was a specialized wheelchair, therapy (physical, occupational, and speech), and a provider to visit resident daily. She said it's the LIDDA caseworker responsibility to upload a resident's Individual Profile to LTC Simple portal after the Interdisciplinary Team meeting. She said since a specialized mattress had not been requested during the IDT meeting, she did not follow-up on it. The Administrator said she remembered she received an email from PASSR (state office) inquiring on a specialized mattress and she had forwarded it to the current MDS/RN B to handle it. She said the current MDS/RN B had responded to the email. The Administrator said MDS/RN B received an email back from PASSR (state office) advising them it had been resolved, she did not remember the date and did not provide a copy. The Administrator said the facility did not have access to the LIDDA's Individual Profiles and did not know the timeframes they had to submit to the Simple portal. She said what she suspected was that the LIDDA caseworker had included a request for a specialized mattress after the IDT meeting without the facility's knowledge. The Administrator said the facility did not have a PASSR policy but did provide their Behavioral Health Services policy. Record review on 08/20/25 of Resident #1's LIDDA's Individual Profile-Nursing Facility dated 01/09/25 reflected:Adaptive Aids and Medical Supplies: Due to recent falls, team agreed to specialized mattress, bolsters and concave mattress to support her from falling off the bed. Record review on 08/20/25 of the facility's Behavioral Health Services policy, dated 08/2017 which reflected: It is the policy of this facility to provide resident with necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well0being, which includes the prevention and treatment of mental and substance use disorders, as well as psychosocial adjustment difficulty, or those with history of trauma and/or post-traumatic stress disorder. Procedure:8. The IDT will also review PASRR recommendations. Event ID: Facility ID: 675933 If continuation sheet Page 7 of 8 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (Cart 1) of 5 medication carts. The facility failed to ensure that the nurses medication cart for 100 hall was secured by a lock when it was left unattended by RN A. These failures could place residents at risk of injury if medication left unsecured were consumed. Findings included: During an observation on 08/20/2025 from 02:40 PM revealed the A Wing Hall nurse's medication cart was left unlocked and unattended against the nurse's station. During the observation RN A approached the nurses' medication cart and notice that was unlocked and the RN A secured the cart by locking it. During an interview on 08/20/2025 at 02:42 PM with RN A revealed she was responsible for the nurse's medication cart that was left unlocked. She stated he was expected to lock the nurse's medication cart when she walked away from it. She stated if it was left unlocked then a resident could open a drawer and take anything that was not for them. She stated he had left the cart unlocked because she just went to another cart to use the computer. During an interview on 08/20/2025 at 04:18 PM with the DON revealed numerous staff, including her and the ADON, were responsible for ensuring medications carts were locked. The DON stated her expectation of staff when they walk away from the medication cart was to lock it. DON stated that the negative outcome for leaving the cart unlocked was that a resident or visitor could grab the medication from the cart, and it could harm them. She stated she had provided in-services to the staff, and she visually monitored daily. Record review of undated facility policy Medication Access and Storage: revealed It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications Event ID: Facility ID: 675933 If continuation sheet Page 8 of 8