Health inspection·January 31, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of four medication carts reviewed for medication storage. -The 300-hall nurse medication cart contained opened out of date liquid and medication not stored in the original packaging. The facility failed to keep resident medications in their original containers/packaging located in the medication cart assigned to LVN M. There were 35 pills that were multicolored/different shapes, 5 1/2 white pills of various shapes and 6 pieces multicolored pills loose at the bottom of one of the drawers belonging to unknown residents. This failure could affect residents receiving medications placing them at risk of receiving the wrong medication and adverse side effects. Findings included: During observation and interview on 01/29/2025 at 12:55 pm, of the Nurse medication cart for the memory unit, which was assigned to LVN M, it had 35 pills that were multicolored/different shapes, 5 1/2 white pills of various shapes and 6 pieces multicolored pills at the bottom of the second drawer on the left side of the cart. A 46-ounce bottle (with approximately 10 ounces remaining) of Thick It thickened water with manufacture expiration date of 07/21/2024 with an open date of 04/04/2024 was found in the bottom drawer on left side. The Manufacturer's instruction on the bottle was to refrigerate after opening and use within 14 days. The loose pills were underneath the medication blister cards that were tightly packed together. LVN M stated she was responsible to keep the medication cart clean and ensure there were no expired medications, liquids or loose pills in the cart. LVN M stated the potential issues were adverse side effects to a resident if loose pills fell out onto the floor and a resident took it or was given an expired medication or liquid. During an interview on 01/30/2025 at 3:15 pm the DON stated the nurses, and medication aide were responsible to clean, remove expired medications/liquid, remove loose pills from the med carts each shift. The DON stated the risks to having loose pills would be not knowing exactly what the pills were for and if a resident were to take a loose pill it could cause side effects, it could cause harm. The DON stated the medication supply could run out for that resident and a refill order would have to be placed. The DON reported her expectation regarding medication carts, was they should be cleaned Page 1 of 3 676252 676252 01/31/2025 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0761 daily, expired oral medications and loose pills be removed each shift. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy titled Storage of Medications. last revision dated November 2020 read in part .Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 4. Drug containers 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. Residents Affected - Few 676252 Page 2 of 3 676252 01/31/2025 Capstone Healthcare Estates at Veterans Memorial 1424 Fallbrook Drive Houston, TX 77038

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for dietary services. 1. The facility failed to ensure foods were sealed, labeled or dated while in storage 2. The facility failed to ensure food on the line was held at temperature of at least 140 degrees and above. These failures could place residents at risk of foodborne illness. Findings included: Observation of the kitchen on 01/28/2025 at 8:20AM revealed the following: - the dry storage container was open to air, unsealed bags of blueberry muffin mix and cereal. - the walk-in cooler contained an open bag of cheese and 3 trays of drinks that were not labeled or dated. Observations of the service line on 01/28/2025 at 8:20AM revealed ground meat that was temped by the Dietary Aide at 140 degrees using a thermometer that was reading 8 degrees degrees too high. In an interview with the Dietary Manager and Dietary Aide on 01/28/2025 at 8:30AM, both stated they did not know the thermometer they used was not calibrated and both stated they did not know how to calibrate the thermometer. At this time, a policy on food storage and hot holding, as well as dietary staff training records were requested from the Dietary Manager, but she did not provide these records prior to exit. In an interview with the Dietary Manager on 01/31/2025 at 9:50AM, she stated that the importance of keeping food resealed and dated was to ensure the freshness of foods and keeping contaminants out of the food that was stored. She reported it was important to know how to calibrate the thermometers to ensure the accurate reflection of appropriate food temperatures while cooking and holding foods. She stated not doing so could put food at risk of sitting in the danger zone therefore increasing the risk of foodborne illness. Record review of the facility's policy on Food Safety for Residents, not dated, reflected, .Bacteria grow rapidly between the temperatures of 40 degrees and 140degrees . 676252 Page 3 of 3