Health inspection·May 30, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3 doses of Clonazepam 1 mg at 9:00 AM, 3:00 PM, and 9:00 PM on 05/15/23, signed off with initials of a staff who was not identified; however, it was not the initials of MA B. Interview on 05/30/23 at 9:50 AM, MA B stated she worked at the facility through an agency and 05/15/23 was her first day ever working there. She stated she was not properly oriented to the facility when she arrived. However, she had knowledge on administering medications, including controlled substances, through her education, trainings, and experience. MA B stated she was given a login to access the system and a key to the medication cart. She stated that she did not count the controlled medications with the off-going nurse and was unsure of how many medications were in the cart before taking over. MA B stated a nurse was taking her key throughout the shift and going in her medication cart. She stated she knew it was not good practice to hand off her key. However, she was new at the facility and did not want to cause problems with the staff. MA B stated she administered 2 doses of Clonazepam to Resident #1 during her shift, at 8:00 AM and 8:00 PM. She stated she was aware that Resident #1 was ordered to receive 3 doses. However, she did not have her key for the afternoon dose and was informed that the medication had been administered. MA B stated she signed off on the CSR for the two doses of medication that she administered and could not recall if she documented the remaining balance of medication. She stated her shift ended at 10:00 PM, and while counting the medications they found that there were missing controlled mediations for Resident #1. She could not recall how many medications were missing. Interview on 05/30/23 at 10:35 AM, the DON stated there was one MA scheduled to work the entire facility on 05/15/23 with a census of about 40 residents. The DON stated agency staff completed a competency and skills check-off before being scheduled for a shift, and they were aware of the expectations before their shift. The DON stated once the medication cart key was handed off to the MA or nurse, it should not be shared between staff. She stated administration of controlled substances should be documented in the MAR and on the CSR to ensure accuracy and prevent medication errors. The DON stated she was informed at approximately 11:00 PM on 05/15/23 that the CSR and medication count did not add up. She stated when she arrived on the morning of 05/16/23, she and LVN A investigated and found that there were no missing medications. The DON stated MA B had filled out the CSR incorrectly, which caused the count to be off. She stated MA B had only signed off for administering 2 doses when 3 doses were given. The DON stated she created a new CSR and added the additional dose, which indicated that the Clonazepam 1 mg was administered three times on 05/15/23 as it was ordered, and that corrected the count. The DON stated she later realized that she should not have created a new CSR to add the additional dose herself, and that she should have had the staff who administered the medication to sign for it on the original CSR provided by the pharmacy. The DON stated the importance of accurately documenting the administration of controlled substance was to ensure that residents received the correct dosages of medications. She stated the risk of inaccurate documenting could be underdosing or overdosing the resident Interview on 05/30/23 at 10:55 AM, LVN A stated he worked on 05/15/23 with MA B. He denied taking the medication cart key during the shift or hearing about other staff taking it. LVN A stated that protocol for taking over a medication cart was to verify the count of all narcotics before receiving the key, and once you have the key it should not be given to anyone else until the end of shift. LVN A stated he assisted the DON with investigating the medication error from the previous night and they found that no medications were missing. However, the CSR was inaccurate. Interview on 05/30/23 at 11:10 AM, Resident #1 stated he had not missed any doses of medications. He stated that he was familiar with his medications and could tell if a dose was missed by how he felt. He stated that he had not experienced any increased spasms or pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 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 676480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mesquite Village Wellness & Rehabilitation 825 W. Kearney Street Mesquite, TX 75149 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's current, undated policy titled Policies and Procedures for Pharmaceuticals Services, reflected in part the following: .Schedule Medication Inventory Sheets: The pharmacy will send scheduled medication sign off sheets for each scheduled medication. The scheduled inventory medication sheet should be completed for each dose administered. .Drug Diversion: The facility must have a system that records receipt, usage, and disposition of all controlled substances in sufficient detail that permits for an accurate reconciliation. .Following Medication Administration: Following resident medication administration, facility staff should appropriately document medication administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676480 If continuation sheet Page 3 of 3