Health inspection·June 11, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview, and record review, the facility failed to ensure resident received adequate supervision and assistance devices to prevent accidents for 1 of 20 resident reviewed for accidents. (Resident #68) The facility did not provide adequate supervision on 05/29/2025 at 7:45AM while transporting Resident #68 in the facility van by the transportation coordinator which resulted in Resident #68 who obtained a fall in the facility van and was sent to the hospital. This failure could place residents at risk for serious injury and accidents. Findings included: Record review of Resident #68's face sheet, printed on 6/10/2025, indicated he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses including muscle weakness (a lack of muscle strength), sciatica, right side, dysphagia, unsteadiness on feet, urinary tract infection, tinnitus of right ear, sepsis, wound myiasis, hyperlipidemia, dementia, nicotine/alcohol dependence, anxiety disorder, hypertension, benign prostatic hyperplasia, adult failure to thrive, more parts of the body), PTSD (a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety), and Type 2 diabetes with chronic kidney disease (a chronic condition that happens when you have persistently high blood sugar levels), polyneuropathy (affects the peripheral nerves, which are the nerves that control the movement of the arms and legs) and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the revised care plan initiated on 6/10/2025 indicated the following: Focus - Resident #68 was at risk for complications due to impaired mobility regarding weakness of right BKA (Below-Knee Amputation), requires assistance with activity of daily living impaired mobility, at risk for injury falls r/t weakness. The right BKA is a surgical removal of the leg below the knee, often due to severe vascular disease or trauma. Record review of Resident #68's quarterly MDS dated [DATE] #68 had a BIMS score of 15, which indicated he a BIMS (Brief Interview for Mental Status) score of 15 indicates that the individual's cognitive function is intact. Record review of the complaint and incident intake worksheet in TULIP created on 5/30/2025 on Resident #68 indicated: Date and time of the incident 5/29/2025 at 11:39am; Date facility first learned of incident 5/30/2025 at 4:17 pm indicated: Update on Resident #68 The driver of the bus called the transportation coordinator who is a licensed vocational nurse. The transportation coordinator alerted Page 1 of 5 676311 676311 06/11/2025 Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the administrator and the director of nursing. They instructed that EMS be called to assess the resident and transport him to the hospital. At the hospital, a CT (CT scan, also known as a computed tomography scan or CAT scan, is a medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body) scan of the spine and head/brain were negative. After a three view X-ray there is no definite injury of the right hand. Per facility intake Resident #68. On 5/29/25 at around 7:43 am the facility van was transporting resident #68 to an appointment when he fell back in his chair. As per facility policy the van parked and called EMS. EMS came to assess resident and was then taken local hospital, Resident returned from hospital at 2:00 PM with abrasion on right hand. The driver claimed that she had secured the front straps to Resident #68 prior to the appointment. The facility interviewed two employees, ECA C and ECA D, who were in the van at the time of the incident. In their statement they could not recall if front straps to wheelchair were secured or not. When Resident #68 returned he testified that the driver, did not apply front straps to his wheelchair and only back straps were applied. A decision was made to terminate the employee (transportation coordinator). Record review of the After Visit Summary dated5/29/2025 indicated the following: Resident #68 you have been evaluated in the Emergency Department today for your head injury. Your CT scan did not show signs of bleeds or fractures in your head. We recommend you take 600 mg ibuprofen every 6 hours or Tylenol 650 mg every 6 hours as needed for pain. Diagnoses: closed head injury, initial encounter, ground level fall, abrasion of right hand, initial encounter. During an interview on 6/10/2025 with Resident #68 who said he remembers the incident from couple of weeks ago he went out for an 8:00 am appointment to the VA for hearing exam. During an interview on 6/10/2025 with HR Director that on 5/29/2025 she notified the nurse at 7:45AM his nurse that Resident #98 had a fall while on transport. It was reported that resident was in his wheelchair on transport van when he fell backwards in wheelchair hitting his head. No bleeding noted. Instructions given to send resident to nearest emergency room for further evaluation and care. Termination of employee (transportation coordinator), review of processes/policies regarding van safety on 5/29/25 by Regional [NAME] President, Regional Clinical Consultant, Maintenance Director and Senior Maintenance Director. Staff educated regarding policy on van safety and response. Drivers to complete safety rounds of van using check list including checking the securement system daily implemented. The Safety Rounds checklist to be provided daily to Maintenance Director to ensure completion implemented. Driver had performed return demonstration regarding van safety rounds and wheelchair securement on 5/29/25. During an interview with maintenance Director on 6/10/2025 at 1:00 pm who said he was responsible for passenger securement safety audits, which was the training of anyone driving the facility van. He said he did a walk around and safety check on 5/28/2025 with the van Driver (transportation coordinator) who they fired, they have now implemented a two-person safety check and walk around. During an interview and demonstrations of van safety on 6/11/2025 at 1:30pm with the administrator/Maintenance Director. Both stated, they could not prove that the van Driver did not strap Resident #68 fully in, but they had implemented a policy to double check on residents being transported via van, they now have a ECA who also checks the securement of the resident in the van. Review of Policy transportation incidents revised June 2025: Purpose to provide transportation for facility residents for appointment and activities away from the facility grounds. 676311 Page 2 of 5 676311 06/11/2025 Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .9. Wheelchair residents will utilize vehicle lift according to manufacturer instructions. Wheelchairs will be secured per manufacturer instructions. 10. Prior to moving vehicle, driver will personally assure that all riders have been safely secured . 12. In the event of any issue that involves a resident tripping, falling, or becoming unsecured or any other situation that may cause an injury to anyone during transportation, including any vehicle accident, the following procedures will be followed. a) The van will immediately move to the nearest safe location off the road and emergency flashers are to be turned on. b) The resident or injured person should not be moved. c) The Nursing Supervisor is to be contacted immediately, director of nursing, and/or administrator. d) In the event of an injury or accident 911 is to be called and EMS and/or police to respond as indicated to evaluate the situation. e) Obtain in writing all details of incident, time, locations, and all persons in the vehicle. f) Prior to moving the transportation vehicle driver must ensure all persons are safe. g) Any time an incident occurs during transport that results in wheelchair tipping in any direction or a resident landing on floor of van, EMS is to be called. Resident is to be evaluated at emergency room. Under no circumstances is the resident to continue to be transported by facility vehicle. h) Upon learning of any incident regarding more that basic first aid from bumping against the lift or doorway of van, the administrator, DON, Regional [NAME] President, Regional Clinical Consultant, Director of Risk Management and Senior Director of Facility Services are to be notified 676311 Page 3 of 5 676311 06/11/2025 Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident # 72) reviewed for pharmacy services. RN A administered a medication prepared by LVN B nurse without verifying the physician's order for the medication and ensuring the medication was the right dose. This failure could place residents at risk for receiving the wrong medication or the wrong dose of a medication resulting in a decline in health status. Findings included: A review of Resident #72's clinical records indicated he was an [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included anxiety, pain, diabetes, dysphagia (difficulty swallowing), gastroesophageal reflux disease (a digestive disease in which stomach acid or bile flows into the food pipe and irritates the lining), and gastrostomy placement (also called a G-tube and is a tube inserted through the belly into the stomach and used for delivering liquid nutrition and water into the stomach). A review of a quarterly MDS dated [DATE] noted Resident #72 had a BIMS score of 9 indicating his cognition was moderately impaired. The same MDS indicated he received nutrition and medications via the G-tube. He was dependent on staff for all activities of daily living. A review of Resident #72's physician orders dated0 6/10/2025 indicated multiple medication orders which included hydrocodone-acetaminophen 5-325 mg tablet every 6 hours via G-tube, lorazepam 0.5mg tablet 3 times daily, and gabapentin 300mg capsule 3 times daily via G-tube. During observation and interviews 06/10/2025 at 12:30 PM, LVN B was observed to prepare 1 tablet hydrocodone-acetaminophen 5-325mg, 1 tablet lorazepam 0.5mg and 1 capsule gabapentin 300mg for administration to Resident #72 via his G-tube. She crushed the tablets, opened the capsule, and placed each medication in its own individual plastic medication cup. She diluted each medication with 5mls of water and carried the 3 medications to Resident #72's bedside table. She administered the 2 tablets separately During the medication administration process, the cup containing the gabapentin medication turned over and part of the medication solution spilled onto the table. She said she would have to obtain and prepare another dose of the gabapentin. RN A who was standing by the wall just inside the room donned (to put on an article of clothing) a gown and gloves and told LVN B that she would hold the G-tube while LVN B prepared another dose of the medication that had spilled. LVN B left the room and went to the medication cart, withdrew a gabapentin 300mg capsule from the cart, opened the capsule, emptied it into a plastic medication cup, diluted the capsule contents with 5mls of water, and re-entered the room. RN A turned toward LVN B and said, Can I do it? LVN B handed the plastic medication cup to RN A and stepped back. RN A poured the medication cup contents into the G-Tube, flushed the tube with 30mls of water, closed the tube, and repositioned Resident #72's clothing. When RN A was asked what medication she gave, she said she gave gabapentin but did not know what the dose was. RN A said she should not have given the medication because she had not prepared it and could not say for sure if the medication was gabapentin, if it was what was ordered by the physician, or if it 676311 Page 4 of 5 676311 06/11/2025 Watkins-Logan-Garrison Texas State Veteran's Home 11466 Honor Lane Tyler, TX 75708

F 0755 was the right dose. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/10/2025 at 01:30 PM, LVN B said she should not have given the medication to the RN to administer. She said since she was the one who obtained, checked, and prepared the medication, then she was responsible for giving it. She said nurses were not supposed to give medications prepared by someone other than themselves. She said RN A could have given the wrong medication or the wrong dose because she had not checked the orders to ensure she was giving the right dose and the right drug. Residents Affected - Few During an interview on 06/11/2025 at 08:15 AM RN A said she should have let the LVN administer the medication because the LVN was the one who prepared it. She said she had not checked the medication to ensure it was the right drug, the right dose, nor the right time to give it. She said she was trying to help the LVN who was nervous and had a lot going on. During an interview on 06/11/2025 at 08:00, the DON said RN A should not have given a medication that she had not personally obtained, checked, and prepared. The DON said she expected the nurses to administer medications in a safe manner. A review of the facility's policy titled Medication Administration indicated the following: Procedure: Always follow five rights: Right medication, Right resident, Right time, Right amount, Right route. 1, Check physician's order for directions on Medication Administration Record (MAR). 2, Check label on medication and compare to the order on the medication administration record. 3. Check for allergies. 4. Wash hands 5. Put on gloves, if necessary. 6. Explain procedure to resident. 676311 Page 5 of 5