Health inspection·May 8, 2025

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 provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 resident (Resident #101) reviewed for pharmaceutical services. The facility failed to ensure RN A followed the physician's orders for administering Mycophenolic Acid, which was used for preventing organ rejection, to Resident #101 on 05/07/25. This failure could put residents at risk of not receiving their medications as ordered. Findings included: Record review of Resident #101's admission MDS assessment, dated 05/4/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included Dementia ( the loss of cognitive functioning, thinking, remembering and reasoning that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance( when a person has trouble telling the difference between what's real and what's not, mood disturbance( less energy, trouble sleeping, trouble concentrating, changes in appetite and motivation, anxiety (feeling of worry, nervousness, or unease, often about something that might happen in the future or current situation), atrial fibrillation (irregular, often rapid, heartbeat that occurs when the heart's upper chambers(atria) don't beat in sync with the lower chambers( ventricles). Hypertension (low blood pressure) , hyperlipidemia ( high lipid/fat in the blood), benign prostatic hyperplasia( a condition that occurs when the prostate gland enlarges blocking the urine stream) without lower urinary tract symptoms, type 2 diabetes mellitus with hyperglycemia ( high glucose level in the blood), immunodeficiency ( when the body's immune response is reduced or absent) due to drugs, kidney transplant, pneumonia, muscle weakness ( Generalized) , cognitive communication deficit. Review of the MDS for admission dated 4/26/25 indicated the resident had no impaired cognition with a BIMS score of 15. Record review of Resident #101's April 2025 Physician's Orders dated 4/30/2025 reflected the following: Myfortic oral tablet delay release (Mycophenolic Acid Dr) .180 mg, Give 3 tablet by mouth two times a day for prevent organ rejection. Record review of Resident #101's blister packet for Mycophenolic Acid Dr.180 mg had (Box warning that reflected: Take on an empty stomach, do not take with antacids, May cause drowsiness, may cause dizziness avoid sun light exposure). Page 1 of 22 676454 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the facility for meal times, undated, revealed breakfast was 8:00 AM, lunch was at 12:30 PM and dinner was at 6:00PM. Observation on 05/07/25 at 9:38 AM, during medication administration revealed Resident#101 was sitting on w/chair in the eating breakfast in his room . RN A administered Mycophenolic Acid Dr 180 mg, Give 3 tablets from blister packet with ((Box warning that reflected: Take on an empty stomach, do not take with antacids, May cause drowsiness, may cause dizziness avoid sun light exposure) RN A administered antacid medication of Pantoprazole Sodium Dr 40 mg 1po, Sodium Bicarbonate antacid 5 g (325 mg) 2 tabs and other medications to Resident #101 by mouth Interview with RN A on 05/07/25 at 9:47 AM regarding administering Resident #101's Mycophenolic Acid Dr 180 mg with Pantoprazole Sodium Dr, Sodium Bicarbonate antacid(both antacid) and other medications to Resident #101 by mouth, revealed she said she had medication training with the DON before she started working with the facility and she started working 2 weeks ago. RN A said she was taught to check the resident name, dosage, frequency, route, time, and expiration date. RN A said she did not look at the box warning on the blister packet. She said if the medication were not as ordered, it would affect the absorption of medications and effectiveness. RN A said she would be changing the time. Interview with the DON on 05/07/25 at 10:34 AM, after showing the DON the blister packet for Resident #101 Mycophenolic Acid Dr180 mg, Give 3 tablets not given in an empty stomach and giving Pantoprazole Sodium Dr 40 mg 1po, Sodium Bicarbonate antacid 5 g (325 mg) 2 tabs (both antacid), the DON said she was going to change the time. She knew not giving Resident #101's medication as ordered by the doctor and following pharmacy recommendation would cause the medication to not to be effective. The DON stated facility had done an in-service on medication administration and the pharmacist on training dated 04/23/25 on medication administration was provided and RN A was in attendance. Interview with the Administrator and DON on 5/7/25 at 5:47PM, the Administrator said her expectation was for medications to be given as ordered by the physician and follow all warning on the blister packet to avoid drug -drug interaction. Record review of the facility trainings revealed an in-service dated 04/22/25 on medication administration and RN A was in attendance. Record review of the facility's current Pharmacy Services policy revision/Reviewed dated 05/2023 and 05/2024, reflected :.Medications are administered in accordance with prescriber orders, including any required time frame. 676454 Page 2 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

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 the medication error rate was not 5 percent or greater. The facility had a medication error rate of 17% based on 6 errors for 34 opportunities. The errors effected2 resident (Resident #101,Resident #20) of 4 residents reviewed for medication administration. Residents Affected - Few -Two medications, Ascorbic Acid tablet 250 mg (used to treat supporting tissue growth and repair, boosting immunity and acting as an antioxidant) and Doxycycline Hyclate oral tablet 100 mg (use to treat infections) for Resident #20 were not dispensed or administered. Four medications: were not administered to Resident #101 Jardiance oral tablet 10mg ( Empaglittozin)( medication use to treat diabetes mellitus) Ascorbic Acid tablet 500 mg Myfortic oral tablet delay release (mycophenolic Acid Dr).180 mg, 3 tablets a day to prevent organ rejection Prograf oral capsule 0.5mg (Tacrolimus drug used to prevent organ rejection) The failures placed resident at risk for inadequate therapeutic outcomes and a decline in health. Findings included: Record review of Resident #20's admission Record dated 05/07/25 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, acute osteomyelitis ( infection of a bone), right ankle and foot, anemia ( not having enough healthy red blood to carry oxygen to the body tissues) hyperlipidemia ( high level fat in the blood), atherosclerotic heart disease of native coronary artery ( chronic disease in which fatty deposits in arteries) , acute kidney failure, acute metabolic acidosis, severe protein-calorie malnutrition, type 2 diabetes mellitus with hyperglycemia , elevated white blood cell count, peripheral vascular disease, muscle weakness (generalized), other abnormalities of gait and mobility, other lack of coordination. The MDS admission dated 4/26/25 indicated resident had moderate impaired cognition with a BIMS score of 15. Record review of the Physician Order dated 04/24/25 for Resident #20 read, in part, . Ascorbic Acid tablet 250 mg. Give 1 tablet by mouth one time a day for supplement and Doxycycline Hyclate oral 676454 Page 3 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0759 tablet 100 mg- Give 1 tablet by mouth two times for infection. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 05/07/25 at 8:30 AM. revealed RN A at that medication cart outside of Resident #20's room. RN A looked at the May MAR and retrieved the following medications from the medication cart and dispensed them into a plastic medication cup: Residents Affected - Few 1 Metoprolol Succ ER 25 mg 1 Po (use to high blood pressure) 1 Amox-Clav 875 -125mg 1 tab po ( antibiotic) 1 Aspirin 81 mg tab po ( used to treat blood clot) 1 Clopidogrel 75 mg 1 tab po ( used to treat blood clot) 1 Magnesium oxide 400 mg 1 po ( used to treat low magnesium) 1 Metformin Hcl ER 500mg 1tab ( used to treat high glucose in the blood ) 1 Heparin 5000 units/ml 10ml = 0.1ml right abdomen SQ( injection used to treat blood clot) Continued observation revealed RN A closed the medication cart and locked it. The Surveyor asked RN A to count the number of tablets/capsules/injection in the medication cup. RN A counted, then answered Seven. RN A entered the room and obtained Resident #20's blood pressure. RN A administered the 7 tablets/capsules/injection to Resident #20. RN A did not administered Ascorbic Acid tablet 250 mg and and Doxycycline Hyclate oral tablet 100 mg to Resident #20 Record review of the May 2025 MAR for Resident #20 revealed the Ascorbic Acid tablet 250 mg. Give 1 tablet by mouth one time a day for supplement and Doxycycline Hyclate oral tablet 100 mg- Give 1 tablet by mouth two times for infection was listed on the MAR as current. RN A had initialed MAR for Ascorbic Acid 250mg and Doxycycline 100mg as administered on 05/07/25 at 9:00 AM Record review of Resident #101's admission MDS assessment, dated 05/4/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included Dementia ( the loss of cognitive functioning, thinking, remembering and reasoning that it interferes with a person's daily life and activities) without behavioral disturbance, psychotic disturbance( when a person has trouble telling the difference between what's real and what's not, mood disturbance( less energy, trouble sleeping, trouble concentrating, changes in appetite and motivation, anxiety (feeling of worry, nervousness, or unease ,often about something that might happen in the future or current situation), atrial fibrillation (irregular, often rapid, heartbeat that occurs when the heart's upper chambers(atria) don't beat in sync with the lower chambers( ventricles). Hypertension (low blood pressure) , hyperlipidemia ( high lipid/fat in the blood), benign prostatic hyperplasia( a condition that occurs when the prostate gland enlarges blocking the urine stream) without lower urinary tract symptoms, type 2 diabetes mellitus with hyperglycemia ( high glucose level in the blood), immunodeficiency ( when the body's immune response is reduced or absent) due to drugs, kidney transplant, pneumonia, muscle weakness ( Generalized) , cognitive communication deficit. 676454 Page 4 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0759 Review of the MDS admission dated 5/3/25 indicated Resident #101 had severe impaired cognition with a BIMS score of 03. Level of Harm - Minimal harm or potential for actual harm Record review of the Physician's Order dated 04/24/25 for Resident #101 revealed: Residents Affected - Few . Jardiance oral tablet 10mg ( Empaglittozin ) Give 1 tablet by po one time a day for DM. Ascorbic Acid tablet 500 mg Give 2 tablets by po one time a day for supplement. Myfortic oral tablet delay release (Mycophenolic Acid Dr).180 mg, Give 3 tablet by mouth two times a day for prevent organ rejection Prograf oral capsule (Tacrolimus), Give 0.5mg capsule by mouth two times a day for rejection prevention of organ. Observation and interview on 05/07/25 at 9:38 AM revealed RN A at that medication cart outside of Resident #101's room. Resident #101 was eating breakfast. RN A looked at the May MAR and retrieved the following medications from the medication cart and dispensed them into a plastic medication cup and administered to Resident #101 by mouth:. 2 Sodium Bicarbonate antacid 5 g (325 mg) 2 tabs po 1 .Stool Softener 100mg1 tab po 1 .COQ10 100mg 1 tablet po 1 Daily Vitamin 1 tablet po 1 Amlodipine Besylate 10 mg 1 tablet po 1 Clopidogrel 75 mg 1tablet po 1 Eliquis 5 mg 1 tablet po 2 Metoprolol Succ ER 50 mg 2 tablet po 3 Mycophenolic Acid Dr.180 mg 3tabs (To prevent organ rejection (Box warning Take on an empty stomach, do not take with antacids, May cause drowsiness, may cause dizziness avoid sun light exposure). 1 Prednisone 5 mg tablet 1 po 1 Pantoprazole Sodium Dr 40 mg 1po 1 Tamsulosin Hcl 0.4mg 1 tab po 1 Vitamin D3 125 mcg(5000iu) 1 tab po 1 Vitamin B1 100 mg 1 tab po 676454 Page 5 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0759 (Injection) Lantus ( insulin glardin injection ) 100 unit/mg 34 unit Level of Harm - Minimal harm or potential for actual harm Continued observation revealed RN A closed the medication cart and lock it. The Surveyor asked RN A to count the number of tablets/capsules/injection in the medication cup. RN A counted, then answered Nineteen RN A entered the room and obtained Resident #101's blood pressure. RN A administered the 19 tablets/capsules/injection to Resident #101. Residents Affected - Few RN A did not administer the following medications to Resident #101: -Jardiance oral tablet 10mg (Empaglittozin)( medication use to treat diabetes mellitus). - Ascorbic Acid tablet 500 mg. -Myfortic oral tablet delay release (mycophenolic Acid Dr).180 mg, 3 tablets a day to prevent organ rejection (Box warning -Prograf oral capsule 0.5mg (to prevent organ rejection). Record review of Resident #101's May 2025 MAR dated 5/7/2025 reflected the following: Jardiance oral tablet 10mg ( Empaglittozin ) Give 1 tablet by po one time a day for DM Ascorbic Acid tablet 500 mg Give 2 tablets by po one time a day for supplement Prograf oral capsule (Tacrolimus), Give 0.5mg capsule by mouth two times a day RN A initialed the above medications as administered on 5/7/2025 at 9:00 AM. Interview on 5/7/25 4:48PM with RN A, regarding not giving medication but initialed as given, RN A said that she went back to ER box to get Doxycycline 100 mg and she gave at a different time. When checked initial time on the computer it was for 9:00 AM. RN A said she was overwhelmed and said if a resident did not get medication as ordered, it could cause a delay in the resident getting well. The Surveyor checked the ER box with the DON at 5:30 PM and there were no Doxycycline in the ER box and there was no sign out sheet available for Doxycycline. In an interview on 05/07/25 at 5:40 PM the DON said the process for administering medications was to identify the resident, then make sure which medications were to be administered by looking at the MAR and pharmacy recommendation. She said the negative outcomes of not getting medications could cause health issues. She said, A lot could happen. The DON said medication given every day should be administered at 9:00 AM and medication given twice a day was at 9:00 AM and 5:00PM. The DON stated the facility had done an in-service on medication administration and the pharmacist on training dated 04/23/25 on medication administration was provided and RN A was in attendance. Interview with the Administrator and DON on 5/7/25 at 5:47PM revealed the Administrator said her expectation was for medication to be given as ordered by the physician and follow pharmacist recommendations. Record review of the facility training log for medication administration revealed in-service dated 04/22/25, RN A was in attendance. 676454 Page 6 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0759 Level of Harm - Minimal harm or potential for actual harm Record review of medication pass times, undated, reflected QD ( every day) was at 9:00AM and BID (twice a day) was at 9:00 AM and 5:00 PM. Record review of the facility policy Medication Administration and Management (revised 04/2024) revealed, in part, .Step III: Administering the Medication Pass Residents Affected - Few 3. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member follows the MAR prepared for the patient/resident by identifying the: The Right Patient/Resident The Right Drug. The Right Dose. The Right Time. The Right Route. The Right Charting. The Right Results. The Right Reason. 676454 Page 7 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

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 of significant medications errors for 1 resident (Resident #20) of 8 resident for medication errors in that: Residents Affected - Some - The facility was unable to locate a current order for Resident #20 for the medication Brilinta (blood thinner/antiplatelet {medication that prevents blood clots}) 90mg oral 1 tablet in the morning and at bedtime. Resident #20 received the medication from 05/01/25 at 9:00PM to 05/07/25 at 9:00PM. This failure placed resident at risk for increase in bleeding and unwanted hospitalization. Findings included: Resident #20: Record review of Resident #20's face sheet dated 05/08/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident diagnoses included the following: osteomyelitis (inflammation of the bone caused by infection) of right ankle and foot, type 2 diabetes mellitus (when the body does not produce enough insulin (a hormone that helps glucose enter the cells for energy) or does not use insulin properly, leading to high blood glucose (sugar), peripheral vascular disease (circulatory condition in which the blood vessels become narrowed reducing blood flow to an extremity) , acute kidney failure (when the kidneys suddenly cannot filter waste from the blood) , atherosclerotic heart disease (damage or disease in the heart's major blood vessels), and hyperlipidemia (high cholesterol). Record review of Resident #20's admission MDS dated [DATE] reflected a BIMS score of 15 indicating the resident's cognition was intact. Further review section O-Special Treatments, Procedures, and Programs reflected that resident was receiving anticoagulant medication. Record review of Resident #20's Comprehensive Care Plan dated 04/24/24 reflected that resident was care planned for receiving anticoagulant therapy with interventions that included the following: -Monitor/document/ report PRN adverse reactions of anticoagulant therapy: blood tinged or blood in urine, black tarry stools, blood in stools, bruising, sudden changes in mental status .or vital signs. Record review of Resident #20's Physician's Order Summary Report for the month of May 2025 reflected the following orders: -Dated 04/23/25 Aspirin 81mg give 1 tablet by mouth one time a day for blood thinner. -Dated 04-24-25 Plavix 75mg give 1 tablet by mouth in the AM for blood thinner. -Dated 04/24/25 Heparin injection (anticoagulant) 5000 units subq (fatty tissue below the skin for example outer upper arm, around the belly, upper thigs and buttocks) BID for blood thinner. -Dated 05/01/25 Brilinta 90mg 1 tablet by mouth every morning and bedtime for blood thinner. Further review revealed that RN Q transcribed this order. 676454 Page 8 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #20's Pharmacy Note dated 05/01/25, Order Note reflected the following: Severity: Severe, Interaction: Brilinta oral tablet 90mg, Plavix oral tablet 75mg may enhanced the anticoagulant effect of heparin, and ASA blood thinner oral capsule 81mg. Record review of Resident #20's MAR/TAR for the month of May 2025 reflected the facility was following physician's orders for ASA, Plavix, and heparin and that resident was being monitored for abnormalities for receiving anticoagulants. Further review reflected the administrations of Brilinta 90mg 1 tablet orally was given in the morning and at bedtime as follows: -1st dose was initiated by the ADON-RN on 05/01/25 at 2100 (9:00PM). -the ADON administered Brilinta on 05/02/25 at 9:00AM. - On 05/02/25 RN N administered the 9:00pm dose on 05/02/25. -On 05/03/25 at 9:00AM RN O administered the medication Brilinta along with other blood thinners. -On 05/03/25, at 9:00PM nurse RN N administered the medication Brilinta. -On 05/04/25 at 9:00AM the ADON administered the morning medications along with Brilinta medication. -On 5/4/25 at 9:00PM RN N administered medications. -On 05/05/25 medications administered by the ADON at 9:00AM and at 9:00PM. -On 05/06/25 morning medications was administered by ADON. -On 05/06/25 at 9:00PM medication administered by RN O. -On 05/07/25 at 9:00AM medication was administered by RN M -On 05/07/25 RN N administered medications at 9:00PM. -On 05/08/25 the medication Brilinta was placed as pending , but did not specify who placed medication as pending. Record review of Resident #20's PT (blood test used to assess how quickly blood clots) and INR (a blood test that measures how long it takes for blood to clot, standardize way of reporting PT results and help to determine correct dosage for blood thinners) collected on 05/06/25. The lab results reflected the following: -PT 23.0 (H) reference range (9.9-11.0) -INR 2.4 (H) reference range (0.8-1.2) Record review of Resident #20's Nursing Progress notes reflected that RN P was the nurse that admitted the resident to the facility on [DATE] with no order for Brilinta 90mg oral 1 tablet in the morning and bedtime. Further review revealed there was no order for the medication Brilinta 90mg oral to 676454 Page 9 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0760 be administered in the morning and at bedtime. Level of Harm - Minimal harm or potential for actual harm Interview on 05/08/25 at 9:05AM with the Pharmacist via phone revealed she came to the facility once a month and was scheduled to come to the facility on [DATE]. The Pharmacist said she was not aware of how many blood thinners that Resident #20 was receiving at the facility. After the P harmacist reviewed Resident #20's medication profile while on the phone with the surveyor said the medication Plavix and Brilinta worked the same and would be considered a duplicate of each other and this would increase the resident's risk of bleeding. The Pharmacist said she would have to see who ordered the medication Brilinta. The Pharmacist said she would maybe recommend the following labs CBC (a common blood test that measures the number of different types of cells in the blood, including red blood cells, white blood cells, and platelets) and PT to be collected to see the resident's blood levels. Residents Affected - Some Interview on 05/08/25 at 9:16AM the DON said she was not aware of Resident #20 being on 4 different types of blood thinners. The DON said she was responsible for reviewing the residents' orders and that Resident #20's medications were discussed in the morning meeting. The DON said she would have to look at her computer and to see what was documented and come back to speak with the surveyor. Observation on 05/08/25 at 9:20AM revealed Resident #20 awake, in bed watching TV ,alert and oriented to person, place, time, and happenings. Resident #20 said he was doing fine and had not experienced abnormal bleeding such as nose bleeding, blood in stool or urine, or bruising of the skin. Resident #20 denied any falls while residing at the facility. Resident #20 had a dressing to his right foot area that was dry and intact with no drainage observed. Interview on 05/08/25 at 9:28AM RN M said she worked at the facility on the morning shift full time 7AM-7PM. RN M said she did not administer the medication Brilinta to Resident #20 for the morning due to the medication being placed on pending but did administer Brilinta 90mg orally on 5/07/25 the morning dose along with resident's other ordered medications. Interview on 05/08/25 at 9:59AM the DON said the medication Brilinta had been placed on pending dated 05/08/25 and that she would have to check to see who placed the medication on pending. The DON began to review Resident #20's records and said it was Resident #20's Dr. at the nursing facility that ordered the medication Brilinta 90mg 1 tablet by mouth in the morning and at bedtime. The DON said when Resident #20 was admitted to the facility a morning meeting was conducted (could not say who all was a part of the meeting). The DON said in the meeting Resident #20's medication heparin was discussed regarding a stop date. The DON said the physician was called on 04/24/25 regarding stop dates on certain medications. The DON said she learned about the new medication Brilinta being added to the resident's medication profile on 05/02/25. The DON said she knew that Brilinta was a blood thinner but did not think anything about it because Resident #20 had a follow-up appointment with the surgical doctor on 05/12/25 due to CAD (coronary heart disease-blood vessel disorder affecting blood supply to the heart). The DON said when a resident was on blood thinners or anticoagulants, the nurse had to monitor for bleeding. The DON said it was RN Q that transcribed the order for Brilinta 90mg 1 tablet by mouth to be administered in the morning and at bedtime. Interview on 05/08/25 at 11:02AM with Resident #20's Primary Care Dr. at the facility said she was notified on 05/08/25 that Resident #20 was receiving the medication Brilinta 90mg 1 tablet by mouth in the morning and at bedtime. The doctor said she did not give the order to administer the medication Brilinta because it would have placed resident at risk for increase bleeding. The doctor said there were no routine lab tests required for medication Brilinta or Plavix. The doctor said she had spoken with the facility and there had not been any negative side effects reported such as abnormal 676454 Page 10 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bleeding or injuries. The doctor said if the resident was experiencing any bleeding, she would have stopped all resident blood thinners and continued to monitor Resident #20 for further bleeding and if so, she would have the facility to send resident to the hospital. The doctor said at this time there were no warrant for further concern and to just continue to monitor resident for signs and symptoms of bleeding. Interview on 05/08/25 at 11:16AM RN P said she worked the night shift 7PM-7AM and could not remember Resident #20. RN P said she was familiar with the medications Brilinta and Plavix. RN P said she believed the medications were administered for heart issues. Further interview with RN P revealed she would not administer the medications Plavix and Brilinta together because they were the same. Interview on 05/08/25 at 12:00PM RN Q said she had been working as a nurse since 2013. RN Q said she had been working at the facility since 04/24/25. RN Q said on 05/01/25, Resident #20 went to a doctor appointment and from the Summary Report that she review ed, she saw the medication Brilinta on the summary report from the doctor visit. RN Q said she noticed that Brilinta was not on resident medication profile and therefore added the medication Brilinta to the resident profile. RN Q did not answer if she saw an order to administer the medication Brilinta, was she familiar with the medication Brilinta, and did she call the doctor for clarification. RN Q said the protocol when a resident returned to the facility and there is a new medication or change in a resident plan of care she was supposed to call the attending physician at the facility to inform of any changes. RN Q said she did not do any of the above and did not answer why she did not take those steps. RN Q said she placed the resident records regarding Brilinta in a box at the nurses' station. Attempted interview via phone on 05/08/25 at 12:30PM with RN N, no answer, left a voicemail with a call back number. Interview on 05/08/15 at 12:58PM the ADON said she initiated the first dose of the medication Brilinta 90mg 1 tab by mouth at 9:00PM on 05/01/25. The ADON said the primary care nurse on duty was nurse RN Q. The ADON said RN Q said she needed some help, and she therefore administered the medication Brilinta to Resident #20. The ADON said she was aware the resident was receiving other blood thinners but never thought to question or clarified the order. The ADON said because she failed to do that, the resident could have bled out (significant and rapid loss of blood). Interview on 05/08/25 at 1:05PM RN M said she worked the morning shift from 7AM-7PM full time. RN M said she was familiar with blood thinner medications. RN M said she chose to administer Resident #20's medications which included Plavix, Heparin injection, Brilinta , and ASA because Resident #20 was not exhibiting any signs or symptoms of bleeding. RN M said she had received in-services on medication administration in regard to anticoagulants/blood thinners. RN M said because the conversation was being had regarding Resident #20's medications, maybe she could have read more about the added medication Brilinta . Interview on 05/08/25 at 1:40PM the [NAME] President of Clinical Operations said the facility was trying to call the doctor office on 05/08/25 regarding Resident #20's doctor visit on 05/01/25 with no reply. The VPCO said the facility had yet to locate an order or a Physician Summary Note for the medication Brilinta 90mg 1 tablet to be administered in the morning and at bedtime. The VPCO said the doctor had not responded to the facility request of medical records for the resident's doctor visits. The VPCO said the facility had in-serviced staff on medication administration regarding blood/thinners, the importance of following up with the physician after a doctor visit regarding any new order. Further interview, the VPCO said the facility had done a 100 % audit on all residents receiving 676454 Page 11 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0760 blood thinners and anticoagulants and there had not been any adverse effects or concerns identified. Level of Harm - Minimal harm or potential for actual harm Further interview on 05/08/25 at 2:17PM the DON said whenever a resident returned from a doctor visit the nurses were supposed to call the attending physician at the nursing facility to inform the doctor of the visit. The DON said RN Q should have called the attending physician at the facility about a new medication for Resident #20. The DON and the Administrator was asked for the facility policy on Medication Administration, Physician Orders, and Transcribing of Orders. Residents Affected - Some Interview on 05/08/25 at 4:02PM via phone, RN O said if a resident was on several blood thinners or anticoagulants, she would review resident's orders and medical diagnoses and inform the physician. RN O said if a resident had a doctor appointment and returned to the facility with new orders, she was supposed to call the attending doctor at the facility to confirm before administering a new medication. Interview on 05/08/25 at 6:11PM the Director of Pharmacy Services said he was not the pharmacist that filled the order Brilinta 90mg 1 tablet orally in the morning and at bedtime for Resident #20. The Director of Pharmacy Services said normally he did not see the medications Plavix and Brilinta given together. The Director of Pharmacy Services said the pharmacy had access to Resident #20's medication profile. The Director of Pharmacy Services said he did not see any documentation of the pharmacist reaching out to the doctor to clarify the order for Brilinta. The Director of Pharmacy Services said the pharmacist that filled the order for Brilinta 90mg 1 tablet by mouth in the morning and at bedtime was not available. Record review of the facility quality assurance dated 05/08/25 revealed that the facility [NAME] President of Clinical Operations had done a 100 % audit on all residents receiving blood thinners/anticoagulants with no duplicate medications. The VPCO had in-serviced the DON and ADON on monitoring all new anticoagulant orders for proper utilization and notifying the MD for any clarification of usage and monitoring tool form. Further review revealed that in-services were conducted with licenses and registered nurses currently in the facility about the utilization of anticoagulants and notifying clinical managers and physician of any signs and symptoms of adverse reactions, order clarification with the facility continuing to Inservice. Further review revealed that the facility had assessed Resident [NAME] Ewing with no adverse reactions at the present time. Record review of staff training revealed that RN M, N, O, P, Q had completed their Nurse Competency Training that included Medication Administration/ 6 Rights of Medication Administration. Record review of the facility policy on Physician Orders revised May 2023 reflected in part: .All medications will be administered as ordered by a health care professional authorized by the state to order medications . Record review of the facility policy Administration of Medication revised April 2023 reflected in part: A physician or nurse practitioner is required for administration of all medications .check medication administration record prior to administering medication for the right medication, dose, route, patient, and time . 676454 Page 12 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0760 Record review of the nursing facility policy on Pharmacy Services revised May 2024 reflected in part: Level of Harm - Minimal harm or potential for actual harm .The provision of pharmaceutical services is an integral part of the care provided to nursing home residents. The management of complex medication regimens is challenging and requires diverse pharmaceutical services and formal mechanisms to safely handle and control medications, to maintain accurate and timely medication records, and to minimize medication related adverse consequences or events. The overall goal of the pharmaceutical service system within a facility is to ensure the safe effective use of medications .Responsible Party: Interdisciplinary Clinical Team . Residents Affected - Some 676454 Page 13 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

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 label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of three medication carts and one of two medication room reviewed for drug for drug labeling and storage, in that: The 200 medication cart reviewed contained heparin 50,000 USP unit per 10 ml 1 vial open not dated (medication used to prevent blood clots). The medication room had 8 cartons of Nurten 2.0 (calorically dense complete nutrition unflavored) that were expired. These failures placed residents at risk for receiving biologicals and medications which were ineffective and/or not safe. Findings include: An observation on 05/07/25 at 3:09 PM of the medication cart checked on the 200 hall with RN A and the DON, revealed inside the medication cart was Heparin 50,000 USP unit per 10 ml 1 vial open and not dated. Observation of the medication room on the 100 hall with the DON on 5/7/25 at 4:00 PM revealed expired Nurten 2.0 (calorically dense complete nutrition unflavored ) High Quality casein -soy protein blend 50% fat 8.45 Fl.oz (250ml) X 8 cartons with an expiration date of April 02 2025. An interview with RN A on 05/07/25 at 3:09 PM revealed she was not aware of the open date not on the Heparin vial. RN A and DON said all open vials should always be dated to know the expired date. Interview with the DON on 5/7/25 4:05 PM, she said she checked the medication room that morning and forgot to check the expiration date and the med rooms were checked weekly for expired meds and Nutren was used for a supplement. The DON threw the Nutren 2.0 away in the trash The DON said using the expired medication/Nutren could place residents at risk for receiving biologicals and medications which were ineffective and/or not safe. During an interview with the DON on 05/07/25 at 10:30 AM , the DON was asked who checked the medication room for expired medications and Nutren supplements and how did they monitor medications. The DON said the night nurses checked the medication room for expired medications. The DON said she did check the medication room periodically and she did not have any daily log for checking medication room. The Pharmacist came once a month and documented the expired meds and discarded them. Record review of the facility policy /Title 5.3 Storage and Expiration of Medications, Biologicals, syringe and needles policy and procedure, dated 12/01/07: Application: LTC Facilities Receiving Pharmacy Products and Services From Pharmacy revealed [in part] . 676454 Page 14 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0761 Procedure . Level of Harm - Minimal harm or potential for actual harm 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label ; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier Residents Affected - Few 676454 Page 15 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 food procurement. 1. The facility failed to ensure foods were dated as opened/prepared discarded after used date of 2 - 3 days per facility policy. 2. The facility failed to store personal food items outside of the kitchen area. 3. The facility failed to ensure food items were sealed and secure. These failures could place residents at risk of food borne illness and disease. Findings Included: In an observation on 05/06/2025 at 08:16 a.m., of the 1 of 1 facility walk-in refrigerators revealed the following: 2-personal fruit trays containing black grapes, not labeled, or dated. 2-Hamburger buns in a bag, used and not labeled. English muffin packaged, half used, not labeled, or dated. 1-gal zip lock bag of croissants, not labeled or dated. 1-small glass bowl with lid, labeled room [ROOM NUMBER] not dated. 1-package of soft tortilla shells not sealed and exposed to air. 1-tray full of 2-ounce dipping sauces containers of hot sauce, not covered/exposed to air, and not labeled or dated. 1-zipped lock bag of kale that appeared to be welted, not labeled, or dated. 24-oz jar of piccata sauce, half used, not dated. 1-bag of cilantro opened, not sealed/exposed to air, and not labeled, or dated. 676454 Page 16 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0812 The Dietary Manager was observed removing all listed items from the refrigerator. Level of Harm - Minimal harm or potential for actual harm In an observation on 05/06/2025 at 08:20 a.m., of the 1 of 1 facility walk-in freezers revealed the following: 1-large box of mixed vegetables not sealed/exposed to air. Residents Affected - Few 1-square plastic measuring bowl of vanilla ice cream not covered/exposed to air, and not labeled, or dated. 2-[NAME] ice cream bars in a box not labeled or dated. 1-small blue bag of corn not labeled or dated. The Dietary Manager was observed removing all listed items from the freezer. In an interview on 05/06/2025 at 8:25 a.m., Dietary Manager (DM) stated she had worked for the facility for 3-years. She stated that the cooks were responsible for ensuring that all staff properly stored, dated, and labeled foods. She stated that the 2-personal fruit trays containing blackberries were left in the refrigerator after a Cinco de Mayo event on 05/05/2025 at the facility and should have been removed at the end of the shift. She stated that the small glass bowl with lid, labeled room [ROOM NUMBER] was her personal bowl from home. She stated she had made hot sauce for the event yesterday had planned to take the sauce home the night before and had forgotten. She stated that the zipped lock bag of kale was used to garnish serving trays on 05/05/2025 and had been surprised to see that it had welted in such a short time, but should have been labeled, or dated. She stated that the tray full of 2-ounce dipping sauces containers of hot sauce were from the 05/04/2025 party and should have been covered and dated. She stated the 24-oz jar of piccata sauce was brought from her home and used to make the hot sauce used on 05/05/2025. She stated it had been her intentions to take the sauce home after her shift on 05/05/2025, but she had forgotten. She stated that the hamburger buns, English muffins, and croissants should have been labeled or dated. She stated that the package of soft tortilla shells and bag of cilantro that were opened should have been sealed, labeled, or dated and if found opened discharged . In an interview on 05/06/2025 at 01:19 p.m., DM stated that 2-personal fruit trays containing black grapes should have been stored in the employee breakrooms refrigerator. She stated that the facility did not have a policy on how or where to store personal food items. She stated that that they were just not supposed to keep personal food in there the kitchen. She stated that leftover foods were to be discharged after 7-days if not used before. She stated after 7-days food items were considered expired and if used, could but residents at risk of food [NAME] illness. She stated that the hamburger buns, English muffins, and croissants, were removed from the refrigerator because it had no opened on and used by date and she was not aware how long those items had been in the refrigerator. She stated she removed the soft tortilla shells because they had not been sealed and had probably lost its flavoring and had become stale and hard. She stated foods uncovered and exposed could get stale, and hard, and if consumed, could make someone ill. She stated the small glass bowl was hers she had brought from home. She stated that she had prepared the hot taco sauce for breakfast for the staff. She stated she placed the leftover in the small bowl to take home, placed it in the refrigerator because she had not wanted it to spoil on 05/05/2025, but had forgotten to take it home. She stated that staff were not allowed to store personal items in the kitchen's refrigerator. She stated that the 676454 Page 17 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few small hot sauce dipping containers should have been thrown away after not being served on 05/05/2025 because they had not place of serving them again. She stated the mix vegetables of peas carrots and corn mixed had been closed and not used. She believed that the box was cut opened, and the sealed bag must have gotten torn in the process. She stated that facility had a 5-gallon container of ice cream and instead of removing the 5-gallan container each time staff needed ice cream, they would scoop ice cream into the square plastic bowl while in the freezer. She stated the ice cream had been covered and dated, but somehow the plastic covering peeled back. She stated that the [NAME] ice cream bars belonged to the facility Activities director and was used as bingo prizes. She stated that she checked the food items for property labeling and storage every day. She stated that she had not had a chance to check on 05/06/2025 before the initial tour of the kitchen began. She stated the provided the dietary staff with an labeling and storage in-service training on 04/22/2025. In an interview on 05/06/2025 at 03:14 p.m., Administrator (ADM), stated that it had been her expectations that the dietary staff following all the rules for proper food storing and labeling to ensure that the food was safe to consume. She stated that the risk of not properly following food process could place residents at risk for gastrointestinal issues. She stated that the dietary manager was responsible for provide the dietary staff education and training on the dietary policies. She stated that the dietary staff received an in-service on proper food storage on 04/22/2025. She stated that the kitchen staff were provided an additional in-service training on 05/02/2025. Record Review of the Nursing Facility (NF)'s in-service record dated 04/22/2025 reflected: Topic Standard Operating Procedure (mandatory). Provided by DM, Chef, signed and dated by dietary staff and the DM. Record Review of the NF's in-service training record dated 05/06/2025 reflected: Provided by: Target Population: Topic: Labeling and Dating. Lecture. Signature is acknowledgement you have been presented with the information and were given the opportunity for questions and clarification, not with agreement to new procedure - dietary staff. Presented by / Signature & Title of in-service DM, Chef. Dated 05/06/2025. Record Review of the NF's Policy titled: FOOD & NUTRITION SERVICES SANITATION & FOOD SAFETY. LABELING AND DATING FOODS and dated 2021 reflected, Policy To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received the date opened and the date by which the item should be discarded. Policy and Procedure Manual. 05/07/2025 at 09:35 a.m. Record Review of the NF's Policy titled: FOOD & NUTRITION SERVICES SANITATION & FOOD SAFETY. LABELING AND DATING FOODS Revised 2017 reflected, PROCEDURE: Refrigerated Food Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. The day of preparation is counted as Day I. For example, food prepared on June 10th will be marked to discard on or use by June 15th. Refrigerated Potentially Hazardous Food or Time/temperature Controlled for Safety foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food item is labeled with the date opened and the date by which to discard or use by. Record Review of the NF's Policy titled: Policy Mandatory Dietary Standard Operating Procedure, undated, reflected, Objective: These standards of procedures aim to enhance food safety, prevent 676454 Page 18 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0812 Level of Harm - Minimal harm or potential for actual harm contamination, maintain hygiene standards, and ensure dietary operations align with regulations. All staff involved in dietary services, including Chefs, Sous Chefs, Cooks, Dietary Aides, and designated employees, are required to adhere to these protocols daily. 4. Labeling and Dating of Food Items Dry Goods: Residents Affected - Few Include received and expiration dates manually, vendor labels are not acceptable. Dented cans should be rejected, labeled appropriately, and reported for credit. Cooler Goods: Items should display prep and use-by dates. Opened items must be labeled with opened and use-by dates. Store food according to the proper order to prevent cross-contamination: A: Ready-to-eat foods. B: Seafood. C: Whole cuts of beef/pork. D: Ground meat/fish. E: Poultry. Freezer Goods: Maintain airtight containers to prevent freezer burn. Clearly label boxes with received and expiration dates. Follow First in First Out practices and appropriate food storage charts. Record Review of the NF's Policy titled: Personal Food General Dated April 2022, revised 05/2023 reflected, It is our practice to support food brought for residents from outside sources. Food provided for a resident by family and visitor will be stored separately from facility food under safe and sanitary conditions. If needed, facility employees will help the resident access food. Safe food handling procedures will be shared with family members to ensure safe and sanitary food storage, handling, and consumption. Responsible party: Guidelines: Purpose: It is our practice to support food brought for residents from outside sources. Food provided for a resident by family and visitors will be stored separately from facility food under safe and sanitary conditions. If needed, facility employees will help the resident access food. Safe food handling procedures will be shared with residents and family members to ensure safe and sanitary food storage, handling, and consumption. Responsible Party· Dietary, Clinical. Guidelines: Securing Food Personal food and safe food handling procedures will be shared with the residents upon admission and as needed.1 Food brought from outside sources by residents, friends or family will be stored in a designated location and labeled as such, separately from facility food. Labeling will include Product Name, received date, Used by date (no 676454 Page 19 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few longer than 3-days), Resident names. Staff members will ensure food id labeled, dated, stored in proper temperature zones, and reheated according to any state or city requirements. Designated staff members will log refrigeration temperatures (2) times per day. Facility staff will be available to assist the resident with personal food access while adhering to safe food handling procedures during reheating or preparation activity in accordance with city or state requirements. Cooking and reheating temperature logs will be maintained and completed when assisting residents. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 676454 Page 20 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission and communicable disease and infections for 2 (Resident #35, Resident #36) of 8 residents whose care was reviewed in that: Residents Affected - Few -The facility failed to label and store resident care items (toothbrush, wash basins, and body cleanser) to prevent cross contamination. They resided in the same room; Resident #35 was bed B and Resident # 36 was bed A. This failure placed residents at risk for infections and decrease in quality of life. Findings: Resident # 35 Record review of Resident #35's face sheet dated 05/08/25 revealed an [AGE] year-old-male admitted to the facility on [DATE]. Resident diagnoses included the following: malignant (cancer) neoplasm (abnormal mass of tissue that results from uncontrolled cell growth) of esophagus (tube that connects the throat to the stomach), type 2 diabetes mellitus (when the body does not produce enough insulin (a hormone that helps glucose enter the cells for energy) or does not use insulin properly, leading to high blood glucose (sugar), paraplegia (loss of movement and sensation in the lower half of the body, including the legs, hips, and buttocks), atrial fibrillation (irregular heart rate that cause poor blood flow), dysphagia (difficulty swallowing), and dementia (decline in a person thinking, learning, and understanding). Record review of Resident #35's admission MDS date 04/20/25 revealed a BIMS score of 6 which indicated the resident's cognition was severely impaired. Review of section GG-Functional Abilities revealed the resident required the use of a manual wheelchair and a walker. Further review revealed that resident was dependent for toilet hygiene, oral hygiene, shower/bathe self, and was occasionally incontinent of urine and frequently incontinent of bowel. Record review revealed that Resident # 35 Comprehensive Care Plan dated 04/14/25 reflected that resident was being care planned for Enhanced Barrier Precautions related to feeding tube and a right heel wound. Interventions involved the use of personal protective equipment, specifically gowns and gloves, during high contact resident care activities (prolonged direct care). Observation on 05/06/25 at 9:17AM of Resident #35 revealed the resident was awake resting in bed receiving enteral feedings Nutren 2.0 at 55ml/hr along with water flush 250ml every 6 hours date hung was 05/06/25 at 6:00AM. Resident #35 was not inter-viewable. Further observation was conducted in the resident's bathroom which revealed a toothbrush sitting on top of the sink behind the faucet not labeled or enclosed. There were 2 wash basins sitting on a wheelchair in the bathroom. The wash basins were not labeled or enclosed. Resident #36 Record review of Resident #36's face sheet dated 05/08/25revealed a [AGE] year-old male admitted to 676454 Page 21 of 22 676454 05/08/2025 Ignite Medical Resort Katy, LLC 1222 Park West Green Drive Katy, TX 77493

F 0880 Level of Harm - Minimal harm or potential for actual harm the facility on [DATE] and discharged on 05/05/25. Resident diagnoses included the following: pneumonia (infection of one or both lungs), subarachnoid hemorrhage (burst blood vessel in the brain), hemiplegia (loss of movement on one side of the body, hemiparesis (weakness on one side of the body) and dysphagia (difficulty swallowing) following cerebral infarction (a type of stroke where part of the brain is deprived of oxygen due to decrease in blood flow to the brain), aphasia (difficulty speaking), and heart failure. Residents Affected - Few Record review of Resident #36's admission MDS dated [DATE] revealed a BIMS score of 14 which indicated the resident's cognition was intact. Section GG- Functional Abilities reflected the resident required the use of a wheelchair. Further review reflected that resident required substantial/maximal assistance with oral hygiene, dependent for toilet, shower/bathe self, and was always incontinent of urine and bowel. Record review of Resident #36's Comprehensive Care Plan dated 04/30/25 reflected that resident was being care planned for Enhanced Barrier Precautions related to pressure ulcers with interventions that included the use of personal protective equipment, specifically gowns and gloves, during prolonged direct contact. Observation on 05/06/25 at 9:17AM of Resident #36's room (same room as Resident #35) revealed the resident was not in his room. Interview on 05/07/25 at 8:50AM with CNA R said she worked at the facility from 7AM-7PM. CNA R said Resident #36 had a change in condition and had to be sent to the hospital. CNA R said all the resident's personal care items should be labeled and bagged for infection control. Interview on 05/07/25 at 10:54AM the DON said the resident's personal care items were supposed to be labeled and bagged for best practices and infection control. Interview on 05/07/25 at 11:00AM with the Administrator regarding policy on resident personal care items, the Administrator said she could not locate a policy regarding the matter. Interview on 05/07/25 at 2:48PM the ADON/Infection Control Preventionist said resident personal care items should be labeled and bagged to prevent cross contamination. Record review of the facility policy on Personal Care Equipment and Storage revised July 2024 reflected in part: .The residents personal care items will be stored in accordance with the resident's preference, and in accordance with state and federal requirements .If in a semi-private room, personal care items will be separated to prevent cross-contamination . Record review of the facility policy on Infection Control dated September 2022 reflected in part: .This facility will follow standard precautions for infection control and prevention to protect residents, staff, and visitors to ensure staff do not carry infectious pathogens on hand or via equipment during resident care . 676454 Page 22 of 22