Health inspection·August 22, 2024

F 0759 Klor-Con 10 meq (potassium chloride) 1 tablet Level of Harm - Minimal harm or potential for actual harm Toprol 25 mg (for blood pressure) 1 tablet Famotidine 20 mg (for GERD) 1 tablet Residents Affected - Few Ranolazine ER 500 (for chest pain) 1 tablet Allopurinol 100 mg (for gout) 1 tablet Tamulosin 0.4 mg (for urinary retention) 1 tablet Aspirin 81 mg 1 tablet Continued observation revealed MA A closed the drawers of the medication cart and locked it. The surveyor asked her to count the number of medications in the cup. MA A counted the medications and said Nine. MA A administered the nine medications to Resident #1. Record review of Resident #1's August 2024 Physician's Orders revealed the resident was to receive 20 meq of potassium chloride, but was administered 10 meq. Continued review of the Orders revealed he was to receive CoQ10 100 mg (for congestive heart failure), a multivitamin, and Calcium 600 mg + vitamin D3 20 mcg (for vitamin deficiency). Those medications/supplements had not been administered. Record review of a Physician's Order dated 08/13/24 revealed Resident #1 was to receive Fexofenadine HCl 60 mg (for allergies) twice daily. The medication had not been administered. Record review on 08/22/24 at 9:00 a.m. of Resident #1's August 2024 MAR revealed MA A had initialed and checked that she had administered the CoQ10 100 mg tablet, the multivitamin, the Calcium 600 mg + vitamin D3 20 mcg, and the Fexofenadine HCl 60 mg. A copy of the MAR was made at that time. In an interview on 08/22/24 at 09:12 a.m., Resident #1 was asked if MA A had returned with additional medications. The resident said MA A had returned to let him know when he could receive a pain medication from the nurse, but she did not bring any additional medications. In an interview and observation on 08/22/24 at 09:15 a.m. MA A said she had given all of the 9:00 a.m. scheduled medications to Resident #1. The surveyor asked her to check the order for the Potassium Chloride. MA A checked the order on the computer and verified it was for 20 meq. She looked at the medication 'blister pack' which had 10 meq tablets. MA A said, Clor-con is 20. It's a 10. I need to give him another one. Observation revealed MA A dispensed and administered a 10 meq tablet to the resident. Record review on 08/22/24 at 1:00 p.m. of Resident #1's August 2024 MAR revealed the CoQ10 100 mg tablet, the multivitamin, the Calcium 600 mg + vitamin D3 20 mcg, and the Fexofenadine HCl 60 mg had been changed to a '9' (not given) instead of a check indicating they were given. In an interview on 08/22/24 at 1:10 p.m., RN B, the Unit Charge Nurse, was asked if MA A had informed her that a resident did not receive all of his medications. RN B said that MA A did not tell her she did not give some medications, but asked her to 'strike out' medications for Resident #1. She said MA A did not give a reason, and she did not ask her why. She said MA A had left the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676479 If continuation sheet Page 2 of 3 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 676479 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 08/22/24 at 1:40 p.m., ADON C said MA A had informed her that Resident #1 did not receive the Calcium with Vitamin D, the CoQ10, and the Fexofenadine. She said she looked at the MAR and they were coded '9', which meant the nurse was verbally informed. ADON C said she could not recall the time MA A informed her. ADON C said that she went to Central Supply, and the medications/supplements were there. The Pharmacy nurse then administered them. The surveyor informed ADON C the MAR had been signed as 'given,' then changed to a code '9'. ADON C said MA A should not have signed them as given. Record review of the the facility policy Medication Administration (no date) read, in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Review MAR to identify medication to be administered .Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676479 If continuation sheet Page 3 of 3