Health inspection·April 24, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (the only medication room) of one medication rooms reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the only facility medication room. These failures could place residents at risk for infection and having possible adverse effects. Findings included: In an interview and observation on [DATE] at 11:23 a.m., expired supplies found stored in the medication room included: 1 - box of 100 count insulin syringes that expired on [DATE] 5 - boxes of 100 count tuberculin syringes that expired on [DATE] The DON was present and stated Central Supply is responsible for monitoring the expiration dates of supplies in the medication room. The DON reported he thought the central supply person checked the dates monthly. The DON stated he expected there not to be any expired supplies in the medication room and was not sure what the risks to the residents would be. In an interview on [DATE] at 9:43 a.m., the DON reported Central Supply was providing transportation to residents and was not available for an interview at this time. The DON reported all expired supplies were removed from the medication room. Record review of facility policy titled Medication Labeling and Storage, with a revision date of February 2023, revealed 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Page 1 of 5 676112 676112 04/24/2025 Crestview Court 224 W Pleasant Run Rd Cedar Hill, TX 75104

F 0760 Ensure that residents are free from significant medication errors. 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 were free of any significant medication errors for one (Resident #52) of four residents reviewed for medication errors. Residents Affected - Few The facility failed to ensure potassium (a mineral supplement used to treat or prevent low potassium levels in the blood) was administered to Resident #52 as ordered from 4/10/2025 until 4/23/2025 (13 days). This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #52's Quarterly MDS assessment dated [DATE] revealed Resident #52 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), respiratory failure, and vitamin deficiency. Section N of the MDS assessment revealed Resident #52 was taking a diuretic (medication that reduces fluid build up in the body). Section C of the MDS assessment revealed Resident #52 had a BIMs score of 07 (suggested severe cognitive impairment). Record review of Resident #52's care plan revised on 4/10/2025 revealed Resident #52 had health problems and medications should have been administered as ordered. Record review of Resident #52's physician order summary on 4/23/2025, revealed an order was entered on 4/10/2025 to administer two tablets of Potassium Chloride ER 20 mEq one time only then to administer one tablet of Potassium Chloride ER 20 mEq twice a day for low potassium levels. Record review of Resident #52's April 2025 MAR revealed Potassium Chloride ER 20 mEq was signed as administered each day from 4/10/2025 until 4/23/2025 (13 days). In an observation on 4/22/2025 at 9:05 a.m., MA A mixed two packets of Potassium 20 mEq powder with water for a total of 40 mEq of Potassium. MA A ensured Resident #52 drank the entire cup of medicine and left the room. In an interview and observation on 4/23/2025 at 10:23 a.m., MA A stated she had followed the directions on Resident #52's MAR, and it had stated to administer two packets of Potassium 20 mEq powder. MA A looked at Resident #52's MAR on her computer screen and pointed to the medication on the screen. The directions under the medication (Potassium 20 mEq) read Potassium Chloride 20 mEq Packet: Mix 2 packets as directed .more. When MA A was asked to click the more link at the end of the directions, additional directions opened up on the computer screen. The additional directions that opened revealed Potassium Chloride 20 mEq Packet: Mix 2 packets as directed; Take by mouth daily for 1 day then 1 packet twice a day. MA A stated she did not realize that there were additional instructions and that the order changed to one packet of Potassium. MA A stated the order was very confusing, and she had given Resident #52 two packets of Potassium 20 mEq (total of 40 mEq) at the same time every day since 4/10/2025. In an interview and observation on 4/23/2025 at 10:53 a.m., the DON looked at Resident #52's MAR on 676112 Page 2 of 5 676112 04/24/2025 Crestview Court 224 W Pleasant Run Rd Cedar Hill, TX 75104

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few his computer. The DON stated he did not know why the MAR was showing to administer packets of potassium when tablets were ordered. The DON looked at Resident #52's medication history, and stated she was taking packets of potassium previously. The DON confirmed the entire directions for the Potassium did not show unless the more option was clicked. The DON reported the nurse managers were responsible for monitoring the medication orders and ensuring the medication orders matched the residents' MARs. The DON stated they changed from one computer charting system to a new system in February and were still learning the new system. The DON stated the expectation was that nursing staff would administer medications correctly. The DON reported the risk to the resident was that if the wrong dose of potassium was given was that they could have developed hyperkalemia (high potassium levels). The DON did not state how high potassium levels could affect the resident. In an interview on 4/23/2025 at 12:23 p.m., the MD reported a stat potassium level (immediate lab) was ordered due to the wrong dose of potassium that was given. The MD stated the risks to the resident from receiving the wrong dose of potassium was that the potassium level could be too high. The MD stated he expected staff to administer medications as ordered and follow the directions. Record review of Resident #52's lab results dated 4/23/2025 revealed Resident #52's potassium level was 3.9 and normal range was from 3.5 to 5.1. Record review of facility policy titled Administering Medications, with a revision date of April 2019, revealed Medications are administered in accordance with prescriber orders. 676112 Page 3 of 5 676112 04/24/2025 Crestview Court 224 W Pleasant Run Rd Cedar Hill, TX 75104

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for food safety. Residents Affected - Some 1. The facility failed to correctly label and date 4 storage bags of cheese. 2. The facility failed to correctly label a cart of water and juice stored in the refrigerator. 3. The facility failed to label and date packages of opened bread. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the dry storage room in the kitchen on 04/22/2025 at 9:40 a.m. revealed a tray with 3 open packages of bread. There were no dates on the open packages. Observation of the walk in refrigerator on 04/22/2025 at 9:46 a.m. revealed a cart with prepared water and juice with no creation or discard dates on the tray or containers. Observation of a the walk in refrigerator on 04/23/23/2025 at 11:25 Am revealed several packages of cheese were observed to be open with only the received date on the packaging. In an interveiw with the [NAME] on 04/22/2025 at 9:46 a.m. she stated that someone put the beverage cart in the refrigerator before she got a chance to put a label on the trays. She stated they all watch for expiration dates and labels. She stated that she tries to make sure everything has a date on it. She stated that she doesnt want any of teh residents to get from anyting coming from the kitchen. In an interview with the DM on 04/22/2025 at 10:15 a.m., he revealed that the bread vendor left the tray of expired bread in the storage room. He took the bread and yelled out the back door for someone to stop the bread man. He stated they usually go by the dates on the packages to determine when to discard out of date bread. He stated that his staff member forgot to put the date on the tray when they poured the water and juice cups. He stated that they were corrected as soon as I left the refrigerator. In an interview and observation with the DM on 04/24/2025 at 11:30 a.m.he stated they usually go by the dates on the packages to know when to discard items. He stated they normally don't last that long. He stated he has a chart in his office with dates detailing how long items should be kept. When looking across the dry storage area packages and boxes of food showed a received date. The DM stated he referred to the chart in his office to know how long each item is kept once its opned. There were 2 packages of opened bread that had no dates on them other than the manufacturers best by date. He stated they were just delivered, but no other dates were included. There were two packages of cheese observed that had been opened and used and they only had the received date on the packages. The DM stated he understood residents could sick from expired food. 676112 Page 4 of 5 676112 04/24/2025 Crestview Court 224 W Pleasant Run Rd Cedar Hill, TX 75104

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record Review of the facility policy Nutrition Services Policy & Proceedurees Food Production & Food Safety Cantex March 2009, Rev 03/2019 revealed 4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must legible and accurately labeled, including the date the package was opened .13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded. 676112 Page 5 of 5