Health inspection·September 2, 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 observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one (Resident #1) of eight residents reviewed for pharmaceutical services. The facility failed to ensure Resident #1 was not self-administering his nasal spray without an assessment and an order for nasal spray on 09/02/2025. This failure could place residents at risk for potential overdose and adverse effects. Findings include: Record review of Resident #1's Face Sheet, dated 09/02/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's Comprehensive MDS Assessment, dated 08/13/2025, reflected the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #1's Comprehensive Care Plan, dated 07/08/2025, reflected the resident had asthma (lung disorder caused by narrowing of the airways) and one of the interventions was to assist the resident in identifying asthma triggers (things, activities, or conditions that could lead to asthma attack). Record review of Resident #1's Physician's Order on 09/02/2025 reflected no order for nasal spray. Record review of Resident #1's Assessment Notes on 09/02/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. Observation and interview on 09/02/2025 at 8:28 AM revealed Resident #1 was in his recliner, awake. A container of nasal spray was observed on top of the resident's side table. He said he was the one administering his nasal spray and he had been doing it for some time. He said he was not sure if the staff knew he was doing it and nobody talked to him that the nurse was supposed to administer his nasal spray. He said his nasal spray had been always in his table where he could easily see it. He said he would not call nor tell the nurse everytime he used the nasal spray. He said he would do it every morning and sometimes if his nose were getting itchy. The resident took the nasal spray from the side table and sprayed once on each nostril (opening of the nose). Observation on 09/02/2025 at 8:32 AM revealed LVN A went inside Resident #1's room to administer his medications. She did not notice the nasal spray on the resident's side table was in plain view. Observation and interview on 09/02/2025 at 8:38 AM, LVN A stated she did not notice the nasal spray on top of Resident #1' side table when she administered his morning medications. She said she was not aware the resident was doing it by himself. She said the nasal spray should not be inside the room because they were medications and she was not sure if the resident could self-administer any medication. She said the resident might use them every hour and no one would know until adverse reactions such as nasal irritation and nasal Page 1 of 5 676168 676168 09/02/2025 Rambling Oaks Courtyard Extensive Care Community 112 Barnett Blvd Highland Village, TX 75077

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dryness. She went inside the room and talked to the resident that she would get his nasal spray and would place them inside the cart. She also told the resident that she would request an order for his nasal spray. In an interview on 09/02/2025 at 11:08 AM, LVN A stated she already took Resident #1's nasal spray and had placed an order for it. She said the nasal spray should be inside the nurses' cart and should be administered by nurses. She said the resident might be confused and took the medication using a different route. She said other residents, that were allergic to the content of the medication, might access the medication and consume it leading to allergic reactions. She said she also checked the rooms of other residents if there were medications inside the room. She said she would also coordinate with the family members to let the nursing staff know if they were bringing any medication. In an interview on 09/02/2025 at 11:50 AM, the DON stated Resident #1's nasal spray should be administered by nurses and there should be a physician's order for it. She said the expectation was for the staff to check if there were any medications inside the residents' room. She said if a resident was administering medications unsupervised, for this incident a nasal spray, there could be adverse effects if the nasal spray was overused such as nose irritation or allergic reactions. She said if the resident was the one administering the nasal spray, there should be an assessment that the resident was able to do so. She said if the resident was deemed able to administer his nasal spray, the nasal spray should still not be on top of the side table were other confused residents could assess it and consume it. The DON said that since the resident was using it, she would check if a physician order was already in place. The DON said she would do an in-service about not leaving any medication inside the residents' room and scanning the room if there were any medications accessible to the residents. In an interview on 09/02/2025 at 12:39 PM, the Administrator stated residents could not administer their own medications unless there was an assessment that the residents were competent enough to do it. She said the resident might overuse the medication resulting to the resident being overmedicated. She said the expectation was for the staff to scan the room if there were any medications at bedside. She said there would be some family members that would bring medications, but still, those medications should not be inside the room and the facility should be aware. She said she would coordinate with the DON on how to make sure that there were no medications inside the residents' room and that no resident was administering any medication by himself. Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, revised 10/25/17 reflected, 1. All medications are administered by licensed medical or nursing personnel . 14. A specific order must be obtained from the Physician Record review of the facility's policy, Medication and Treatment Orders 2001 MED-PASS, Inc revised July 2016 reflected Policy Interpretation and Implementation . 1. Medications shall be administered only upon the written order . 3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. 676168 Page 2 of 5 676168 09/02/2025 Rambling Oaks Courtyard Extensive Care Community 112 Barnett Blvd Highland Village, TX 75077

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the medications were stored properly in locked compartments or provided a safe and secured storage with limited access for three (Residents #1, #2, and #3) of eight residents reviewed for medication storage. 1. The facility failed to ensure Resident #1's nasal spray was not left inside the resident's room on 09/02/2025. 2. The facility failed to ensure Resident #2's zinc oxide (medicated cream used to prevent skin irritation) was not left on top of the resident's side table on 09/02/2025. 3. The facility failed to ensure Resident #3's zinc oxide was not left on top of the resident's side table on 09/02/2025. These failures could place residents at risk to have access to medications that could result to accidental ingestion and misuse of medications. Findings include: 1. Record review of Resident #1's Face Sheet, dated 09/02/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease. Record review of Resident #1's Comprehensive MDS Assessment, dated 08/13/2025, reflected the resident had a moderated impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #1's Comprehensive Care Plan, dated 07/08/2025, reflected the resident had asthma and one of the interventions was to assist the resident in identifying asthma triggers. The care plan did not indicate that the resident could administer his nasal spray. Record review of Resident #1's Physician's Order on 09/02/2025 reflected no order for nasal spray. Record review of Resident #1's Assessment Notes on 09/02/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment the resident was competent to manage their own medications. Observation and interview on 09/02/2025 at 8:28 AM revealed Resident #1 was in his recliner, awake. A container of nasal spray was observed on top of the resident's side table. He said the nasal spray had been with him for a while. Observation on 09/02/2025 at 8:32 AM revealed LVN A went inside Resident #1's room to administer his medications. She did not notice the nasal spray on the resident's side table that was on plain view. Observation and interview on 09/02/2025 at 8:38 AM, LVN A stated she did not notice the nasal spray on top of Resident #1' side table when she administered his morning medications. She said the nasal spray should not be inside the room because the nasal spray was considered as a medication. She went inside the room and talked to the resident that she would get his nasal spray and would place them inside the cart. In an interview on 09/02/2025 at 11:08 AM, LVN A stated she already took Resident #1's nasal spray and placed it inside the nurses' cart. She said the resident might be confused and took the medication using a different route. She said other residents, that were allergic to the content of the medication, might access the medication and consume it leading to allergic reactions. 2. Record review of Resident #2's Face Sheet, dated 09/02/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with protein-calorie malnutrition (a form of malnutrition that could impact the skin causing dryness, roughness, and flakiness). Record review of Resident #2's Comprehensive MDS Assessment, dated 08/01/2025, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 04. The Comprehensive MDS Assessment indicated the resident had protein-calorie malnutrition and was incontinent for bladder and bowel. Record review of Resident #2's Comprehensive Care Plan, dated 09/02/2025, reflected the resident had incontinence and one of the interventions was to apply barrier cream after each episode if needed. Record 676168 Page 3 of 5 676168 09/02/2025 Rambling Oaks Courtyard Extensive Care Community 112 Barnett Blvd Highland Village, TX 75077

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some review of Resident #2' Physician Order, dated 08/19/2024, reflected May apply barrier cream as needed. Observation and interview on 09/02/2025 at 8:41 AM revealed Resident #2 in her wheelchair eating breakfast. It was observed that a tube of zinc oxide was on the resident's side table. When asked if the staff left the zinc oxide on her side table after using it, the resident replied with uncomprehensible words. In an interview on 09/02/2025 at 10:26, CNA B stated she was assigned on Resident #2 and did not notice the zinc oxide on the resident's side table. She said the zinc oxide should be inside the nurse's cart and not at bedside because the resident might eat it. She said she would check Resident #2's room if the zinc oxide was still there and would also check the other rooms of the residents on her hall. 3. Record review of Resident #3's Face Sheet, dated 09/02/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with age-related debility (general decline in physical and mental function due to aging). Record review of Resident #3's Quarterly MDS Assessment, dated 07/03/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated the resident was incontinent for bladder. Record review of Resident #3's Care Plan, dated 08/15/2024, reflected the resident had potential for pressure ulcer related to incontinence and one of the interventions was to apply barrier cream per physician order. Record review of Resident #3's Physician Order, dated 09/20/2024, reflected May apply barrier cream as needed. Observation on 09/02/2025 at 8:51 AM revealed Resident #3 was in his bed with eyes closed. It was observed that a tube of zinc oxide was on top of the resident's side table. In an interview on 09/02/2025 at 10:31 AM, CNA C stated she was assigned on Resident #3' hall for the day. She said she did not notice the zinc oxide on Resident #3's side table. She said it should not be accessible to the residents because they might confuse it as food and put it in his mouth. She said she would check if the zinc oxide was still inside the resident's room. She said she would also check the residents' rooms on her assigned hall. She said she did change the resident and applied some barrier cream, but she could not remember if she put it inside the drawer or not. In an interview on 09/02/2025 at 11:08 AM, LVN A stated zinc oxide was a form of medication because it was used to prevent skin issues such as rashes, irritations, and minor burns. She said it should not be left inside the rooms of the residents as confused residents might consume it. She said the cream should be stored in the cart and just put some in a cup for use or place it somewhere not accessible to the residents. She said she would go to Resident #2 and Resident #3's rooms to get the zinc oxide. She said she would also check the rooms of the other residents to see if there were zinc oxides inside the room In an interview on 09/02/2025 at 11:50 AM, the DON stated zinc oxides should not be left or stored inside the resident's room because some residents might be able to get hold of the zinc oxide because the tubes were in plain view. She said the CNAs and the nurses were responsible in checking if there were zinc oxides were inside the residents' rooms. She said she already made her round when she was made aware about the zinc oxides being inside the rooms of the residents. She said zinc oxide was applied topically and could be harmful when ingested. She said, when ingested, some of its ingredient might cause allergic reactions or some adverse reactions such as stomach upset, nausea, and vomiting. She said the expectations were for the staff to always scan the residents' rooms to make sure they were not leaving the tubes of zinc oxide inside the room, putting them where the resident could not access them, or just put them in the cart. She said she would do an in-service about storing the zinc oxide accordingly. In an interview on 09/02/2025 at 12:39 PM, the Administrator stated the expectation was for the staff not to leave the zinc oxides inside the room of the residents after use. She said the residents, confused or not, could access and consume them and could result to untoward outcomes such as allergy or interaction with other oral medications. 676168 Page 4 of 5 676168 09/02/2025 Rambling Oaks Courtyard Extensive Care Community 112 Barnett Blvd Highland Village, TX 75077

F 0761 Level of Harm - Minimal harm or potential for actual harm She said she would coordinate with the DON about storing the tubes of zinc oxide inside the carts or somewhere not accessible to the residents. Record review of the facility's policy, Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, revised 10/25/17, revealed, 8. After the medication administration process is completed . stored in a locked medication room, or otherwise secured. Residents Affected - Some 676168 Page 5 of 5