Health inspection·March 11, 2025

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concern, it was determined that a medication error had occurred. Resident #1's physician was notified and an order to monitor residents' vital signs and assess for side effects of the medication was received. Record review of Resident #1's nursing progress notes dated 1/6/2025 at 12:47pm written by LVN A indicated Resident #1 was transferred to the hospital related to Resident #1 received the wrong medication and Resident #1's requested the transfer for further monitoring. Record review of Resident #1's nursing progress notes dated 1/6/2025 at 12:57pm written by LVN A indicated Resident #1 received the wrong medication (glatiramer acetate 40mg/ml) that morning at 8:00am. Resident #1 had been monitored since and had shown no adverse reactions. Resident #1's vital signs were blood pressure 104/57 (normal is less than 120/80), pulse 71 (normal 60-100), temperature 97.7 (normal 97-99). Resident #1's lungs were clear on both sides, rise and fall of chest was equal. Injection site showed no signs of redness or irritation. Resident #1's pupils were equal and reactive. Resident #1 was conscious and responsive. Resident #1's strength was equal to upper and lower extremities. Resident #1's requested Resident #1 be sent to the hospital . Record review of Event Nurses' Note dated 1/6/2025 written by LVN B indicated . 5. Nursing description of the event: was concerned about medication for multiple sclerosis being given to Resident #1 because she was unaware that he had that diagnosis. Upon investigation of this concern, it was determined that a medication error had occurred. 17. One on one in servicing with nurse for medication error, Monitoring of the patient, all nursing staff in serviced on medication administration. Record review of Discharge -Summary V4 dated 1/6/2025 at 3:00pm indicated: A. Reason for discharge: Resident went to the hospital and chose to go to another facility after discharge from the hospital. Record review of hospital paperwork dated 1/6/2025 indicated No likely effect from Glatiramer Acetate use. During an interview on 3:10pm at 2:54pm LVN A said she had been off of work for a couple of weeks and when she came back to work there were 2 residents with similar names that were next door to each other. She said she went to give Resident #1 the injection he lifted his shirt as if he had always received the medication so she administered the medication. She said Resident #1's was there and asked what she had given him and when she told the said she was not aware that Resident #1 was diagnosed with multiple sclerosis. She said upon investigation of the diagnosis of multiple sclerosis it was determined that a medication error had occurred. She said she notified the DON, and ADON immediately. LVN A said Resident #1's requested Resident #1 be sent to the hospital for monitoring. She said after the incident she was in serviced regarding medication administration and was put with a preceptor for a few days following the incident. Record review of facility Licensed Nurse Proficiency Audit dated 11/19/2024 indicated: LVN A had shown to be satisfactory with administering medications properly. Record review of facility policy Medication Administration Procedures revised 10/25/2017 indicated: 4. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. Record review of Ad Hoc QAPI dated 1/6/2025 regarding medication error with attendees that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675960 If continuation sheet Page 2 of 3 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 675960 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Castle Pines Health and Rehabilitation 2414 W Frank Ave Lufkin, TX 75904 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 0760 included: Administrator, DON, ADON, Medical Director, Social Services, Regional Clinical Nurse, and the Area Director of Operations. Level of Harm - Minimal harm or potential for actual harm Record review of Inservice titled Medication Administration dated 1/6/2025 and 1/7/2025 signed by LVN A. Residents Affected - Few Record review of Inservice titled Resident Rights dated 1/7/2025 signed by LVN A. Record review of Inservice titled Medication Not Available dated 1/7/2025 signed by LVN A. Record review of Inservice titled 7 Rights of Medication dated 1/7/2025 signed by LVN A. Record review of Inservice titled Medication Error dated 1/7/2025 signed by LVN A. Record review of Inservice titled Abuse/Neglect dated 1/7/2025 signed by LVN A. Record review of Inservice titled Resident Rights dated 1/7/2025 signed by all staff. Record review of Inservice titled Abuse/Neglect dated 1/7/2025 signed by all staff. Record review of Inservice titled Medication Administration dated 1/7/2025 signed by nurses and medication aides. Record review of Inservice titled Medication Not Available dated 1/7/2025 signed by nurses and medication aides. Record review of Inservice titled Medication Error dated 1/7/2025 signed by nurses and medication aides. Record review of Inservice titled 7 Rights of Medication dated 1/7/2025 signed by nurses and medication aides. Record review of Licensed Nurse Proficiency Audit prior to the incident dated 11/19/2024 and after the incident dated 1/7/2025. During interviews 3/10/2025 at 3:13 pm through 3/11/2025 10:06am the following nurses and medication aides were able to properly describe the medication administration procedure and the 7 rights of medication administration, what to do if medication is not available, what to do in case of a medication error, and abuse and neglect: LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, MA G, MA H, MA J, LVN K, RN L, LVN M, LVN O. The noncompliance was identified as PNC. The noncompliance began on 1/6/2025 and ended on 1/8/2025. The facility had corrected the noncompliance before the survey began. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675960 If continuation sheet Page 3 of 3