Health inspection·September 9, 2022

F 0727 Sunday August 21, 2022 Level of Harm - Minimal harm or potential for actual harm Saturday August 27, 2022 Sunday August 28, 2022 Residents Affected - Some An interview on 9/9/22 9:58 a.m., the DON stated she is not always able to have RN's on the weekends, she has scheduled the staffed but they may call in for illness. The DON stated pool nurses and agency is called for assistance with staffing. The DON stated she and the Assistant Director of Nursing will cover weekends when needed. The DON stated the reason for having RN's 7 days a week is because they have advanced training, anticipate, identify and respond to change in condition, are able to perform higher level tasks, work in an advisory position and are able to delegate tasks. She stated it is difficult to hire and are currently advertising for weekend staff on a job search website. An interview on 9/9/22 11:30 a.m., the Administrator stated she is aware there has been difficulty staffing weekends with RN's. She stated the facility is actively attempting to hire RN's with multiple venues. She stated she has offered bonuses, ride share, gas cards for hiring and maintaining the RN staff. She stated she the importance of having RN's 7 days a week included oversight and advanced decision making related to level of education. Record review of the Departmental Supervision policy statement dated 2001, revealed the nursing services department shall be under the direct supervision of a Registered Nurse/Charge Nurse. The Policy Interpretation and Implementation revealed #2. A Registered Nurse is employed as the DNS The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a Nurse Supervisor/Charge Nurse is responsible for the supervision of all nursing department activities including the supervision of direct care staff. #3. The Nurse Supervisors/Charge Nurses are RN and are duly licensed by this state. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 2 of 9 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 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 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 assure the accurate dispensing and administration of all drugs or biologicals) to meet the needs of each resident and ensure expired and discontinued drugs or biologicals were not available for use in 1 of 3 nurses med cart (LVN D), reviewed for pharmacy services. The facility failed to ensure two opened Lidocaine 1% multi-dose vials partially used, and without an open date or resident name, were removed from the nurse's med cart (LVN D). The facility failed to ensure the IV Ceftriaxone 1 gm antibiotic and OTC meds were not stored next to the wound care supplies, in nurse's med cart (LVN D). These failures could place all residents at risk of not receiving the intended therapeutic benefit of their medications, and the potential to facilitate drug diversions. Findings included: During observation on [DATE] at 1:00 p.m. of LVN D's med cart revealed an IV antibiotic Ceftriaxone 1 gm in 100 ml NS was found next the wound care supplies, creams and ointments. Further observed a box with contents of OTC two natural tears eye drop and two ear wax removal drops were stored next to the wound care supplies. During observation on [DATE] at 1:00 p.m. of LVN D's med cart revealed two opened Lidocaine 1% multi-dose injectable vials, partially used and without an open date. Observed no resident name on the accessed multidose vials. Interview on [DATE] at 1:00 p.m., LVN D confirmed the IV Ceftriaxone 1 gm antibiotic should not be stored next to the wound care supplies including OTC meds, eye drops and ear wax removal drops. LVN D stated the two lidocaine 1% multidose vials were opened and accessed, but he did not know which resident it was used on. He stated the multidose vials were partially used, with no open date or resident name on it. He stated he knew it should have been removed from the med cart. Interview on [DATE] at 2:30 p.m., the DON confirmed the IV antibiotic Ceftriaxone 1 gm and OTC meds, eye drops, and ear wax removal drops were not supposed to be stored next to wound care supplies. She stated nurses were responsible to dispose of unlabeled, opened multidose vials and meds labeled properly. She stated moving forward will ensure nurses and MA's keep med carts organized, and she would in-service staff. Interview on [DATE] at 11:35 a.m., ADON stated the IV Ceftriaxone 1 gm antibiotic found in LVN D's med cart was scheduled to start in p.m. but should not be placed next to wound care supplies. ADON stated she would re-educate staff that accessed multidose vial should have an open date, resident name and while being used, placed in a bag to keep med sterile. Record review of the facility provided in-service titled, In-Service Training Report dated [DATE], revealed upon opening multi-dose vial, to have date opened and patient name needed. Further noted cart organization - carts must be organized based on med category. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 3 of 9 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 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on [DATE] at 10:00 a.m., the Administrator stated moving forward we would follow up all issues on medications with QAPI. Record review of the facility's policy titled, Storage of Medications dated [DATE] reflected in part, the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Drugs that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Event ID: Facility ID: 676252 If continuation sheet Page 4 of 9 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 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 0759 Ensure medication error rates are not 5 percent or greater. 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 that the medication error rate was not five percent or greater. The facility had a medication error rate of 11%, based on three errors out of 27 opportunities, which involved two of five residents (Resident #55 and Resident #35) and two of 4 staff (MA A and MA B) reviewed for medication administration, in that: Residents Affected - Some MA A failed to administer the Lidocaine (for pain) 5% patch to Resident #55, as ordered by the physician. MA A failed to administer the correct amount of Levetiracetam ER (Keppra, for seizures) to Resident #55, as ordered by the physician. MA B failed to administer the correct dosage of calcitonin salmon nasal spray (used to treat osteoporosis) to Resident #35, as ordered by the physician. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Resident #55 Record review of Resident #55's clinical record, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebrovascular accident (CVA or stroke), transient alteration of awareness, cerebral infarction (lack of adequate blood supply to the brain) and diabetic neuropathy (pain or numbness due to nerve damage with diabetes). Record review of Resident #55's Care plan dated 7/13/21, revealed the resident would receive all care as per physician's order. Notify the physician and family of changes of condition. Observation on 9/08/22 at 9:20 a.m. with MA A during med pass with Resident #55 revealed a Lidocaine 5% 1 patch was removed on her mid-chest, and then MA A applied a new Lidocaine 5% 1 patch to her mid-chest or sternum. Further observed Levetiracetam (Keppra) ER 500 mg 1 tablet by mouth was administered to Resident #55. Record Review of Resident #55's physician's order, dated September 2022, revealed to give the following: -Levetiracetam ER (for seizures) 1500 mg 1 tab po q 12 hrs, for CVA, start date 6/07/22. -Lidoderm patch 5% (Lidocaine) apply to chest topically q day, remove at bedtime; remove per schedule, start date 8/23/22. Further noted for inflammation to sternum. Record Review of the MAR, dated September 2022 revealed Resident #55 received the following medications: Levetiracetam ER (for seizures) 1500 mg 1 tab po q 12 hrs, for CVA, start date 6/07/22. Lidoderm patch 5% (Lidocaine)apply to chest topically q day, remove at bedtime (qHS), remove: 0759 (7:59 a.m.) apply: 8:00 a.m. Further noted for inflammation to sternum, start date 8/23/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 5 of 9 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 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 9/08/22 at 3:10 p.m., the DON stated she would follow-up that MD order complete, accurate and reflected in Resident's MAR, and physician order followed. The DON confirmed Resident #55's Keppra order was not followed which was to give Keppra 1500 mg dose. She stated MA A only gave 1 tab Keppra 500 mg instead of 500 mg 3 tabs=1500 mg, as ordered by the physician. Interview on 9/08/22 at 3:15 p.m. the DON stated staff should have used the change of direction sticker for instructions on the medication, to give Keppra 500 mg 3 tabs=1500 mg to the resident. She stated MA's should verify physician order with the nurse and if still unclear to let the ADON and DON know. Interviewed MA A on 9/08/22 at 3:20 p.m. MA A stated she had been assigned to Resident #55 in hall 200 and administered her scheduled morning Keppra dose including the Lidocaine patch. She stated she had verified with the nurse and was told she can give the 1 tab of Keppra 500 mg. She stated there was not a Keppra 1500 mg tab available for the resident; the only available dose was Keppra 500 mg tab. MA A further stated what she sees in Resident #55's MAR was Lidocaine 5% patch apply at 8:00 a.m. and remove: at 7:59 a.m., instead of bedtime (q HS). Interview on 9/08/22 at 3:25 p.m. the DON stated Resident #55's Lidocaine 5% patch order was not followed which was to remove patch at bedtime. She stated she would correct Resident #55's MAR, since it did not reflect MD order, with the correct time to remove Lidocaine 5% patch q HS, as ordered by the physician, and in-service staff. Interview on 9/09/22 at 11:35 a.m. MA B when asked, she stated that MA's do not put the direction change sticker but nurses. She stated that the Keppra order should have been clarified in Resident #55 's MAR, to give Keppra 500 mg 3 tabs=1500 mg. Interview on 9/09/22 at 11:35 a.m. the ADON stated will ensure the correct dosage and quantity of Keppra tabs administered to Resident #55, and the nurses, not MA's, put the change in direction sticker instruction on the med. She stated the pharmacy only dispense Keppra 500 mg tablets, and not Keppra 1500 mg tabs. The ADON stated Resident #55's corrected Keppra order, will now read to give 500 mg 3 tabs =1500 mg. She stated 1:1 instruction was given to MA A, to read and follow the physician's order as reflected in Resident #55's MAR, to give Keppra 1500 mg 1 tab dose, not 500 mg tab. She stated MA A could not tell us, which nurse did she verify the Keppra order for Resident, and will in service the nurses and MAs. Interview on 9/09/22 at 1:40 p.m. the DON stated Resident #55 's stat Keppra level was drawn, and the result was reviewed by the NP. She stated it was noted to continue the Resident #55's Keppra order. Interview on 9/09/22 at 11:50 a.m. the Administrator stated moving forward we would follow up all issues on medications with QAPI. Resident #35 Record review of Resident #35's clinical record revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of osteoporosis (fragile bones), adult failure to thrive (decreased appetite, poor nutrition), Alzheimer's disease and dementia. Record review of Resident #35's Care plan dated 7/13/21, revealed the dietician to evaluate and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 6 of 9 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 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 0759 make diet change recommendations, and Resident #35 would receive adequate nutrition. Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #35's physician's order, dated September 2022, revealed to give calcitonin salmon solution (used to treat osteoporosis) 200 unit/ml 1 spray to alternating nostrils, start date 7/12/22. Further noted indicated, for calcium inhibitor. Residents Affected - Some Observation on 9/08/22 at 9:40 a.m. during med pass for Resident #35 revealed MA B administered one spray of calcitonin (salmon) solution 200 unit/ml nasal spray, into both nostrils (used to treat osteoporosis). Interview on 9/09/22 at 11:35 a.m. MA B stated she did not understand the alternating nostrils order for Resident #35's calcitonin nasal spray. She stated next time before administering meds, that she would verify the order with charge nurse or the ADON. Interview on 9/09/22 at 11:40 a.m. the ADON stated MA B was instructed regarding alternating nostrils order. She stated Resident #35's calcitonin alternating nostril spray order was corrected, to include which nostril to administer the spray, Rt nostril and then the Lt nostril the next day. Interview on 9/09/22 at 11:50 a.m. the Administrator stated moving forward we would follow up all issues on medications with QAPI. Record review of the facility's policy titled, Administering Medications dated April 2019 reflected in part, medications are administered in a safe and timely manner, and as prescribed. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences . the person preparing or administering the medication will contact the prescriber . to discuss the concerns. Record review of the facility's policy titled, Medication and Treatment Orders dated July 2016 reflected in part, orders for medications and treatments will be consistent with principles of safe and effective order writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 7 of 9 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 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 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 from significant medication errors for 1 of 5 residents (Resident #55) reviewed for significant medication errors in that; Residents Affected - Few MA A did not administer Resident #55 's Levetiracetam (Keppra, for seizures) medication, as ordered by the physician. Resident #55 did not receive Lidocaine (for pain) 5% patch, as ordered by the physician and med was not correctly transcribed. These failures could place residents at risk of an overdose, not receiving the intended therapeutic benefits, increased negative side effects and decline in health. Findings included: Record review of Resident #55's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebrovascular accident (CVA or stroke), transient alteration of awareness, cerebral infarction (lack of adequate blood supply to the brain) and diabetic neuropathy (pain or numbness due to nerve damage with diabetes). Record review of Resident #55's Care plan dated 7/13/21, revealed the Resident will receive all care as per physician's order. Notify the physician and family of changes of condition. Observation on 9/08/22 at 9:20 a.m. with MA A during med pass with Resident #55 revealed Levetiracetam (Keppra) ER 500 mg 1 tablet by mouth was administered to Resident. Further observed MA removed an old Lidocaine 5% 1 patch on her mid-chest, and then MA A applied new Lidocaine 5% 1 patch to her mid-chest or sternum. Record Review of Resident #55's physician order, dated September 2022, revealed to give the following medication: Levetiracetam ER (for seizures) 1500 mg 1 tab po q 12 hrs, for CVA, start date 6/07/22. Lidoderm patch 5% (Lidocaine)apply to chest topically q day, remove at bedtime; remove per schedule, start date 8/23/22. Further noted for inflammation to sternum. Record Review of the MAR, dated September 2022 revealed Resident #55 received the following medications: Levetiracetam ER (for seizures) 1500 mg 1 tab po q 12 hrs, for CVA, start date 6/07/22. Lidoderm patch 5% (Lidocaine)apply to chest topically q day, remove at bedtime (qHS), remove: 0759 (7:59 am) apply: 0800. Further noted for inflammation to sternum, start date 8/23/22 Interview on 9/08/22 at 3:10 p.m., the DON stated she would follow-up that MD order complete, accurate and reflected in resident's MAR, and physician order followed. The DON confirmed Resident #55's Keppra order was not followed which was to give Keppra 1500 mg dose. She stated MA A only gave 1 tab Keppra 500 mg instead of 500 mg 3 tabs=1500 mg, as ordered by the physician. Interview on 9/08/22 at 3:15 p.m. the DON stated staff should have used the change of direction sticker for instructions on the medication, to give Keppra 500 mg 3 tabs=1500 mg to the resident. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 8 of 9 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 676252 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038 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 stated MA's should verify physician order with the nurse and if still unclear to let the ADON and DON know. Level of Harm - Minimal harm or potential for actual harm Interviewed MA A on 9/08/22 at 3:20 p.m. MA A stated she had been assigned to Resident #55 in hall 200 and administered her scheduled morning Keppra dose including her Lidocaine patch. She stated she had verified with the nurse and was told she can give the 1 tab of Keppra 500 mg. She stated there was not a Keppra 1500 mg tab available for the resident; the only available dose was Keppra 500 mg tab. MA A further stated what she sees in Resident #55's MAR was Lidocaine 5% patch apply at 8:00 a.m. and remove: at 7:59 a.m., instead of bedtime (q HS). Residents Affected - Few Interview on 9/08/22 at 3:25 p.m. the DON stated Resident #55's Lidocaine 5% patch order was not followed which was to remove patch at bedtime. She stated she would correct Resident #55's MAR, since it did not reflect MD order, with the correct time to remove Lidocaine 5% patch q HS, as ordered by the physician, and will in-service staff. Interview on 9/09/22 at 11:35 a.m. MA B stated that MA's do not put the direction change sticker but nurses. MA B further stated the Keppra order should have been clarified in Resident #55 's MAR, to give Keppra 500 mg 3 tabs=1500 mg. Interview on 9/09/22 at 11:35 a.m. the ADON stated she would ensure the correct dosage and quantity of Keppra tabs administered to Resident #55, and the nurses, not MA's, put the change in direction sticker instruction on the med. She stated the pharmacy only dispense Keppra 500 mg tablets, and not Keppra 1500 mg tabs. ADON stated Resident #55's corrected Keppra order, now read to give 500 mg 3 tabs =1500 mg. She added 1:1 instruction was given to MA A, to read and follow the MD order as reflected in Resident #55's MAR, to give Keppra 1500 mg 1 tab dose, not 500 mg tab. She stated MA A could not tell us, which nurse did she verify the Keppra order for Resident, and will in service the nurses and MAs. Interview on 9/09/22 at 1:40 p.m. the DON stated Resident #55 's stat Keppra level was drawn, and the result was reviewed by the NP. She stated it was noted to continue the Resident #55's Keppra order. Interview on 9/09/22 at 11:50 a.m. the Administrator stated moving forward we would follow up all issues on medications with QAPI. Record review of facility provided policy titled, Administering Medications dated April 2019 reflected in part, Medications are administered in a safe and timely manner, and as prescribed. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences . the person preparing or administering the medication will contact the prescriber . to discuss the concerns. Record review of facility provided policy titled, Medication and Treatment Orders dated July 2016 reflected in part, Orders for medications and treatments will be consistent with principles of safe and effective order writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676252 If continuation sheet Page 9 of 9