Health inspection·November 6, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and if he needed his call light, he would not try to reach it if it was on the floor because he knew he would fall. He stated he would yell out for help if he needed help and sometimes it took a while for staff to answer his light if he could reach it to call for them. In an observation on 11/04/24 at 12:25 PM Resident #144 was lying in bed with the call light lying on the floor on the right side of his bed and out of Resident #144's reach. Resident #144's door was open, and Resident #144 was not showing any sign of pain or distress. In an interview on 11/04/24 at 12:22 PM CNA C stated she had worked in the facility for about 2 years. She stated she had not seen Resident #144's call light on the floor or out of his reach. She stated Resident #144 could not have reached the call light where it was on the floor, and he probably had gotten up to go to the bathroom and it fell on the floor. She stated she had been in-serviced on call lights being within residents reach. She stated residents call lights should have been in residents reach at all times and if a residents call light was out of reach, it could cause a fall. In an interview on 11/06/24 at 10:54 AM, the DON stated residents call lights should be in all residents reach at all times. She stated all nursing staff and any other staff that entered a residents room were responsible for ensuring call lights were in residents reach at all times and all staff had been in-serviced on call light placement. She stated if a residents call light was not in reach, it could have caused a delay in care or assistance. In an interview on 11/06/24 at 11:02 AM, the ADM stated she stated residents call lights should be in all residents reach at all times. She stated all staff were responsible for ensuring call lights were in residents reach at all times and all staff had been in-serviced on call light placement. She stated if a residents call light was not in reach, it could have caused a resident to possibly not have their needs met. In an interview on 11/06/24 at 11:08 AM a policy for call lights or call light placement was requested from the ADM. The ADM stated there was no policy from the facility for call lights or call light placement. The ADM stated it was their expectations for all call lights to be in place and to answered in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676289 If continuation sheet Page 2 of 6 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 676289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Atrium of Bellmead 2401 Development Blvd. Bellmead, TX 76705 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 - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to ensure 3 expired Central Line Dressing Change Kits, 3 expired I.V. Start Kits and 1 Pack of 30 expired syringes of Ativan/Benadryl 1-25mg/ml medications were removed from the medication storage room located near Nurse's Station 2. There were no active orders for the medication. These failures could place residents who needed intravenous medications at risk to have contaminated dressings or contaminated I.V. lines started. This would put them at risk of infection. The failure to removed expired medications could put residents at risk of receiving ineffective medications. Use of these expired supplies and medications would not meet acceptable standards of medical practice and could result in resident's harm. Findings include: Observation on 11/05/2024 at 2:37 pm of the Medication Room on Station 2 revealed the following items with expired Manufacturer/Supplier dates: #3 HTo3-7600 Dressing Change Central Line Kit by Cardinal Health Expired 10/1/24. #3 IV Start Kit with/Chloraprep App by Medline Item # DYND74260 Expired 7/31/24. #1-Pack of 30 1ml syringes Ativan/Benadryl 1-25 mg/ml Lipo Topical Expired 10/27/24. In an interview on 11/6/24 at 10:55 am, the DON stated the policy on expired items in the medication storage room was for them to be destroyed and placed in the destroyed bin and reordered. She stated the nurses, and the medication aides were responsible for this and that they have been given in-services on this. The DON stated the potential outcome if this was not done, would be that expired medications and supplies could cause harm like infections to residents. In an interview on 11/6/24 at 11:00 am, the ADM stated the policy on expired items in the medication storage room was for them to be destroyed. The ADM stated that anyone who has access to the medication room was responsible for doing that, including nursing and nursing management. She stated that they have been in-serviced on this. She also stated the potential outcome if not done was that expired medications may not have the correct effectiveness and expired supplies may not have the original integrity. A lack of integrity for supplies could cause a break in a sterile field, which would create a potential risk for infection. She stated a prudent nurse would not use expired items. In an interview on 11/6/24 at 12:18 pm, LVN-A stated the policy on expired items in the medication storage room was to put them into the hazardous bin, sign-off on them, and then the DON can dispose of them later. She said nurses and medication aides were responsible for doing this and that they have been in-serviced on this. She stated the potential negative outcome if this was not done, and expired meds or supplies were used was that expired medications may not be effective and expired supplies could break and allow bacteria in to cause infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676289 If continuation sheet Page 3 of 6 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 676289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Atrium of Bellmead 2401 Development Blvd. Bellmead, TX 76705 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 In an interview on 11/6/24 at 12:20 pm, MA-B stated the policy on expired items in the medication storage room would be to put them in the discontinued box or if it was a narcotic, then give it to the DON. She stated the medication aides, and the nurses were responsible for doing this and they have been in-serviced on it. MA-B stated the potential negative outcome if this was not done, and expired meds or supplies are used is that expired medications lose their effectiveness and expired supplies could also not be effective. Residents Affected - Few Record review of the facility policy dated 2003 and titled, Pharmacy Policy and Procedure Manual Policy-Storage of Medication reflected, Medications and biologicals are stored safely, and properly following manufacturer recommendations or those of the supplier. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676289 If continuation sheet Page 4 of 6 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 676289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Atrium of Bellmead 2401 Development Blvd. Bellmead, TX 76705 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 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 1 of 1 kitchen reviewed for dietary services in that: 1) Dietary staff failed to effectively reseal, label and date items in the walk-in refrigerator. 2) Dietary staff failed to effectively label items in in freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During the initial tour of the kitchen on 11/04/2024 at 09:11 AM the following was observed: The walk-in refrigerator contained what appeared to be cabbage in a clear opened plastic bag that was exposed to air and not labeled or dated. The freezer contained what appeared to be croissants in a clear plastic bag with no label. Interview with the Dietary Manager on 11/05/24 at 11:05am, the DM stated all items in the refrigerators and freezers should be sealed, labeled, and dated. The DM stated if an item was not sealed properly the item could spoil or there would be a cross contamination issues. The DM stated if an item was not labeled then someone would not know what the item was. The DM stated it was the cook or aide who opened the items responsibility to ensure they were labeled, dated, and properly sealed. Interview with the ADM on 11/05/24 at 11:50am, the ADM stated all items should be sealed, labeled, and dated. The ADM stated that if food was not sealed properly the food would not be safe to serve and would not be palatable. The ADM stated that if an item was not labeled then it may not be identified correctly. The ADM stated whoever opened the item would be responsible for ensuring it was sealed, labeled and date properly. Record review of the facility's Food Storage and Supplies policy, dated 2012, revealed All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedures: 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when open . Record review of the facility's Storage Refrigerators policy, dated 2012, revealed All storage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676289 If continuation sheet Page 5 of 6 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 676289 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Atrium of Bellmead 2401 Development Blvd. Bellmead, TX 76705 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 0812 refrigerator shall be maintained clean and have a proper temperature for food storage and ensure a proper environment and temperature for food storage. Level of Harm - Minimal harm or potential for actual harm Procedures: Residents Affected - Many 5. Food must be covered when stored, with a date label identifying what is in the container . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676289 If continuation sheet Page 6 of 6