Health inspection·June 12, 2023

F 0760 Poisoning by other opioids, accidental (unintentional), initial encounter with start date 06/08/23. Level of Harm - Actual harm Record review of Resident #1's Medication Record for June 2023 revealed Resident #1 received a fentanyl patch on 06/01/23, 06/04/23, and 06/07/23. Residents Affected - Few Record review of Resident #1's nurse's notes, dated 06/08/23 at 11:13 AM, revealed LVN A documented naloxone order injection updated to spray per [Nurse Practitioner] Electronically Signed by [ADON] 06/08/23 10:48 AM as per NP (nurse practitioner), to send her hospital. CN (certified nurse) spoke to family [family member] and as per family preferences to [hospital]. CN called 911 and EMS team is arrived in 5 minutes, and she sent out with med list, face sheet and recent labs. Record review of Resident #1's hospital paperwork, dated 06/08/23, revealed Resident #1's diagnosis included ARF (Acute Renal Failure), Hyponatremia (the sodium level in the blood is below normal), UTI (Urinary Tract Infection), Diastolic Echo (Echo in 82022 EF (ejection fraction) 55-60%), Afib (type of abnormal heartbeat), AMS (altered mental status), Jaundice (a condition produced when excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat)/Transaminitis (an elevated level of certain liver enzymes), and Chronic pain/ RA (rheumatoid arthritis). The hospital paperwork revealed nurse's notes dated 06/08/23 at 12:09 PM stated Limited ROS (Review of Systems- an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced.) otherwise however patient was noted from the facility to have 2 transdermal fentanyl patches on with her MAR from the outside facility showing only supposed to be on 1 patch every 72 hours. In an interview on 06/09/23 at 3:23 PM, Resident #1's FM stated Resident #1 was hospitalized on [DATE] and the hospital nurse told her that resident was overdosed because she was admitted into the facility with two fentanyl patches. Resident #1's FM stated when they saw Resident #1 in the hospital, she was very lethargic and was unable to have a conversation. The FM stated this was not her normal baseline. In an interview on 06/12/23 at 10:45 AM, the NP stated multiple nurses reported that Resident #1's behavior had changed, and she seemed lethargic. She stated she assessed Resident #1 on 06/08/23. The NP stated Resident #1's skin was yellow, she had slurred speech, and her face was drooping. The NP stated Resident #1 received fentanyl patches and she thought maybe she had been overly medicated, so she ordered Narcan (naloxone). She stated after Resident #1 received the Narcan, she was more alert and was able to speak. The NP stated after Resident #1 was more alert, Resident #1 stated she was in pain, so she gave orders to send her to the ER. In an interview on 06/12/23 at 10:54 AM, LVN A stated it had been reported by staff that Resident #1's behavior had changed. She stated the NP assessed Resident #1 on 06/08/23. LVN A stated the NP had concerns that Resident #1 could have opioid overdose, so gave an order for naloxone, via nasal cavity. She stated after Resident #1 was provided the naloxone and the NP gave an order to send her out to the ER. LVN A stated she did provide the fentanyl patch on 06/07/23 and placed it on her right arm. She stated there was one already there and she removed it but did recall how she disposed of it. She stated they were allowed to either flush it down the toilet and or put it in the red disposal box on the medication cart. LVN A stated a lot of times she has the ADON to watch while she throws away the patch because it is best practice, but that day she was busy and did not have time to get the ADON. LVN A stated the DON asked her about this situation as well because Resident #1's FM reported Resident #1 had two patches at the hospital. LVN A stated on 06/07/23 there was only one patch on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676192 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 676192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garnet Hill Rehabilitation and Skilled Care 1420 McCreary Rd Wylie, TX 75098 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 Level of Harm - Actual harm Residents Affected - Few her arm. She stated the only explanation she could think of as to why Resident #1 had two patches is that maybe one fell off in the bed and one of the CNAs saw it and put it back on. LVN A stated there had not been any CNAs reporting a patch fell off. In an interview on 06/12/23 at 1:44 PM, the DON stated on 06/09/23 Resident #1's FM had reported she felt Resident #1 was overly medicated because she had two fentanyl patches on arm when she admitted to the hospital. She stated she immediately started an in-service on 06/09/23 about ensuring there is only one patch. The DON stated she did review the hospital paperwork for Resident #1 and saw that she admitted into the hospital with two patches. She stated she did review Resident #1's diagnosis from the hospital paperwork and this error did not contribute to her underlying health issues. The DON stated due to this situation she had changed the policy, which would require two nurses to verify the old patch was disposed of and the new patch was applied. The DON stated the risk to the resident is they could have an overdose. Record review of the facility's policy titled Documentation of Administration and Removal of Narcotic Transdermal Patches, undated, The Narcotic Transdermal Patches are powerful, Schedule II narcotics used to manage moderate to severe pain. Although available in other dosage forms, when used in the form of an extended?release transdermal patch it confers pain relief to individuals over a 72?hour period. Customarily, the patch is applied externally to the individual, left intact for 72 hours, and then replaced with a new patch. 4. Remove the patch 72 hours after application. This should be done at the same time every 72 hours. 7. Apply patch to non-irritated skin such as chest, back, flank or upper arm. 13. Documentation requirements: a. Documentation of patch placement q shift. b. Removal of old patch BEFORE placement of a new patch. c. Removal of old patch must be witnessed by 2 nurses and documented on the narcotic control sheet.14. Removed patches must be folded inward, medication to medication, and placed in the original sheath/package. a. Used patches are to be disposed according to the current facility policy regarding disposal of narcotic drugs. b. Dispose in secured pharmaceutical waste container per appropriate medical waste management regulations. c. Patches may not be disposed of in Sharps containers in the resident's room. They must remain under lock and key until destroyed or rendered unusable per current facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676192 If continuation sheet Page 3 of 3