Inspection·October 12, 2023

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of law enforcement report# 23-00542 authored by Officer C, dated 08/08/23, in reference to R#1, revealed: Family Member A alleged that CNA A forged three checks totaling $14,000. Case was forwarded to Officer D for review.[ Information was not available in the said law enforcement that captured the interview with Officer D] Record review of R#6's admission inventory sheet dated 7/29/22 revealed: the resident had a purse but the items in the purse were not inventoried; to include the existence of a checkbook. Record review of R#6's Nurse Note dated 08/08/23 revealed Family Member B alerted the facility to possible misappropriation the resident was transferred to a hospital for an infection to her amputated left lower extremityy.; [which did not allow the facility to interview the resident about the alleged misappropriation.] Record review of R#6's CP dated 07/28/22 revealed the resident had impaired cognitive function and impaired thought processes related to depression and anxiety. An intervention included for staff to communicate with the resident over her needs. Record review of employee CNA A's timecard revealed last day of employment was 07/20/23 at 5:55 PM. Record review of facility's investigative file dated 08/15/23 revealed: CNA A wrote a thank you comment note, undated, to R#6, thanking her for help given. Record review of facility's employee file for CNA A revealed: CNA A was arrested by law enforcement on 08/26/23 and released 08/27/23. During a telephone interview on 10/11/23 at 8:20 PM, R#6 stated: I never wrote checks to an employee at the nursing home or to a CNA .the CNA [A] may have stollen checks from my checkbook which I carried in my purse . R#6 stated that [Family Member B] was addressing the stollen check situation with law enforcement. She (R#6) heard from [Family Member B] that the CNA [CNA A] was arrested for the theft of the checks and forging her signature. R#6 stated, she [CNA A] stole the checks. R#6 was angry over the stollen checks and the monies taken from her checking account. R#6 stated she was not familiar with the following individuals listed on the checks: CNA A Check # 3537 dated 07/06/23 for $1,083; Party E Check # 3541 dated 7/20/23 for $3,000; Party E Check # 3545 dated 7/25/23 for $3,000; and Party F Check # 3549 dated 08/02/23 for $8,000. R#6 stated she had a lot of money; but was angry over the misappropriation of checking funds. During a telephone interview on 10/12/23 at 8:26 AM, Family Member B stated: resident (R#6) wrote a check on 07/06/23 to CNA A as a loan to be paid back in 90 days. The CNA gave her a sad sorry. The other checks were written without the permission of the resident. I visited the administrator and was encouraged to make a police report The family member became suspicious after the $8,000 check written on 08/03/23 to a Party F. Family Member B stated Party E was related to CNA A. Family Member B stated: I know this for a fact because I have worked with [Party E] in the community .and later found out that [Party F was related to CNA A]. Family Member B stated that CNA A got into the resident's purse and took the three stolen checks. During a joint interview with the DON and the administrator on 10/12/23 at 10:59 AM, the DON stated: she had no direct knowledge of the incident on 8/8/23. The DON stated that nursing staff should not request favors or monetary rewards or gifts from residents; and it was part of abuse/neglect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 2 of 9 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 676481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive Port Lavaca, TX 77979 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some training. The Administrator stated: on 08/08/23, he was informed by a [Family Member B] that possible forgery of checks occurred involving R#6 and CNA A. The family member intended on calling the police; and the administrator stated he would also call the police and HHS. The Administrator stated he suspended the employee pending an investigation; and could not get a written or verbal statement from the employee [CNA A]; the employee's last date of work was 07/20/23. The employee [CNA A] was terminated after 8/8/23 because, evidence revealed CNA A engaged in misappropriation. Preventative measures put in place included: in-service training on abuse/neglect for all staff. R#6 was to be offered again a locked box once she returned from the hospital. HHS and physician were notified. At the time of the reported incident by Family Member B , R#6 was hospitalized for her knee infection. During a telephone interview on 10/13/23 at 12:15 PM, CNA A stated she provided ADL care to R#6 for over one year and they got closed. The ADL care involved showering, transfer and bed mobility with another staff, and incontinent care for both bowel and bladder. The incontinent care was only provided by CNA A without another staff member being present. In July 2023, CNA A shared with R#6 that she was experiencing some financial hardship. R#6 wrote CNA A check for $1,083 (on July 6, 2023) as a loan. CNA A did not inquire or got approval from facility management to accept the check. CNA A stated she had received training from the facility on abuse and neglect which included not to accept gifts or money from residents. CNA A stated that her financial difficulties lead her to take the check for $1,083. CNA A added that she was not thinking right. CNA A stated that in reference to check # 3541 ($3,000 to Party E), #3545 ($3,000 to Party E) and #3549 ($8,000 to Party F) she took the checks from R#1's purse and signed the checks as R#6. CNA A stated that Party E and Party F were related to her. CNA A stated, I was stupid for signing the checks [forged signature belonging to R#6]. CNA A stated she was arrested [08/26/23 and released 08/27/23] for the misappropriation of the checks and realized her actions could jeopardize her certifications as a CNA and Medication Aide. CNA A stated the misappropriation was wrong and that she was trying to put her life together. Record review of CNA A's employee filled revealed last abuse/neglect training was completed on 05/23/23. Date of hire was 04/06/23 and last date at work was 07/20/23CNA A received abuse/neglect training during orientation (date of hire was 04/26/23). EMR dated 04/04/23 and criminal history check dated 04/04/23 revealed no negative information. Record review of facility's grievance log date range August 2023 to October 12, 2023, revealed: no allegations of misappropriation. Record review of facility's Abuse, neglect, and Exploitation Policy & Prevention Program dated January 2020 read: .Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . It was determined this failure placed residents in Past Non-Compliance from 07/06/23 until 08/08/23.The facility took the following action to correct the non-compliance: Record review of employee CNA A's timecard revealed last day of employment was 07/20/23 at 5:55 PM. Record review of facility's employee roster dated 10/12/23 revealed a total of 149 employees on payroll; not including CNA A. Record review of facility's Inservice training from 08/08/23 to 10/12/23 revealed 207 employee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 3 of 9 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 676481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive Port Lavaca, TX 77979 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some signatures; all staff completed abuse/neglect training to include misappropriation at a percent of 100% (Number of paid employees equaled 149 on 10/12/23). Record review of facility's investigative file, undated, revealed: HHS notified on 08/08/23-finding of facility's internal investigation was unconfirmed pending the police investigation. Incident sheet dated 01/26/23 revealing R#6 refused a locked box. Police report # 23-00542 dated 08/08/23. Date of employee's last date of work was 07/20/23. CNA A terminated 08/08/23. CNA A arrested 08/26/23 and released 08/23/23. Record review of facility's Resident Council minutes revealed that on 09/12/23 minutes, abuse/neglect was an agenda item. Observation and interview on 10/12/23 at 7:47 AM, R#2 was in bed; receiving continuous 02 at 2.5 liters per minute; alert and oriented to person and place. There was a locked safe in the resident's room. The resident stated: they have taken it [resident did not describe what was taken] .in the past .staff .do not know what was taken .do not remember how long the safe box has been here I feel safe here .I have no complaints Observation and interview on 10/12/13 at 7:55 AM of R#3 revealed: there was a safe in the room. R#3 was in bed alert and oriented watching TV. The resident stated it was a personal choice to have a strong box . The resident stated that he had not experienced any theft. R#3 stated that last week $187 was returned to him by a laundry staff member. He had left the money in a shirt pocket sent to the laundry. The staff in the facility was described as honest by the resident. As vice president of the Resident Council, the resident stated that in the past ninety days no resident had voiced a complaint about missing money or property. I have never heard of staff stealing money or valuables. During an interview on 10/12/23 at 8:09 AM, CNA G[day (6 AM-6 PM) and night shift (6 PM-6 AM)]stated she received training on abuse and neglect a couple of months ago and the highlight was to report misappropriation if suspected. The abuse coordinator was the Administrator. During an interview on 10/12/23 at 8:13 AM, CNA H [day shift] stated she received training on abuse and neglect a couple of weeks ago. The highlight of the misappropriation was to report to the Administrator. During an interview on 10/12/23 at 8:17 AM, CNA I [day shift] stated: she received training on abuse and neglect a couple of months ago. The highlight of misappropriation was to report it to the Administrator. She had worked with CNA A for a couple of months; and CNA had poor work habits in that being absent. During an interview on 10/12/23 at 8:39 AM, CNA J [day shift and night] stated: she received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 4 of 9 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 676481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive Port Lavaca, TX 77979 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some training on abuse and neglect a couple of months ago. The highlight of the misappropriation training was to report it to the Administrator. She had worked with CNA A for a couple of months; CNA was described as having medium work habits;' not defined. During an interview on 10/12/23 at 8:43 AM, CNA K [day and night shift]stated: she received training on abuse and neglect a couple of weeks ago. The highlight of the misappropriation training was to report to the Administrator and not take things from residents. During an interview on 10/12/23 at 8:49 AM, CNA L [day and night shift]stated: she received training on abuse and neglect a couple of months ago and the highlight was to report misappropriation if suspected. The abuse coordinator was the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 5 of 9 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 676481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive Port Lavaca, TX 77979 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revised the Comprehensive Care Plan for 1 of 12 residents (R#1 ) reviewed for revision of the Care Plan. R#1's Care Plan was not revised or documented new interventions after the resident was involved in four residents to resident altercations. This failure could denied the interdisciplinary team information on recommended interventions for dealing with resident to resident altercations. The findings included: Record review of Resident #1's face sheet, dated 10/10/23, and EMR (electronic medical record) revealed, the resident was re-admitted on [DATE] with diagnoses that included: fluid in the lung, emphysema, muscle wasting, dementia, delusional disorders, insomnia, anxiety, depression, and Alzheimer's disease. Resident was a male age [AGE]. RP (responsible party) was listed as: family member. Resident was housed in the secured unit of the facility. Record review of R#1's BIMS score dated 9/14/23 revealed a score of zero (severely impaired). Record review of Resident# 1's Care Plan, 04/25/23 , revealed, the goals and interventions for a resident with dementia and behaviors included: monitoring, encourage the resident to communicate needs, document, and report, as needed, any changes ., and assess. Further review revealed the CP read .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document Record review of facility's incident reports involving R#1's resident to resident altercations revealed: On 05/14/23, R#1 came in contact with R#4's face. Staff nurse separated the residents; assessed and there were no injuries. Staff nurse did not revise the CP for R#1 involving a resident to resident altercation initiated by R# 4 as the aggressor. The incident report did not mention whether the CP was revised. On 09/02/23 at 4:00 PM, R#1 was yelling at R#5 and an allegation surfaced that R#1 struck R#5 in the face. Both residents were separated, and assessment of both residents revealed no injuries. Staff nurse did not revise the CP for R#1 involving a resident to resident altercation initiated by R# 5 as the aggressor. The incident report did not mention whether the CP was revised. On 09/02/23 at 5:00 PM, R#1 struck in the face R#5. Both residents were separated; assessed and there were no injuries. Staff nurse did not revise the CP for R#1 involving a resident to resident altercation initiated by R# 1 as the aggressor. The incident report did not mention whether the CP was revised. On 09/03/23 at 6:00 PM, R#1 made contact with R# 5's chest. Residents were separated; assessed and there were no injuries. New intervention was the relocation of R#5's to another room outside the secured unit. R#1 was placed on 15 minute monitoring. Staff nurse did not revise the CP for R#1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 6 of 9 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 676481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive Port Lavaca, TX 77979 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few involving a resident to resident altercation initiated by R# 6 as the aggressor. The incident report did not mention whether the CP was revised. Record review of R#1's physician orders, dated September 2023, revealed: psychotropic medications for R#'1's dementia and behaviors included: Trileptal Oral Tablet 150 MG (Oxcarbazepine) Give 1 tablet by mouth two times a day for delusions . Trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime for insomnia/depression . The physician's orders included referring R#1 to psychiatric and psychological services as needed. During an interview on 10/10/23 at 3:32 PM,LVN M stated the CP dated 4/25/23 was not capturing specific dates of aggression and any new interventions . LVN M stated, the CP should reflect episodes of aggression or falls so as to communicate resident needs and interventions attempted. LVN M added, the management team should communicate episodes of aggression at routine meetings and request an update of the CP. LVN M stated R#1's CP could have been updated at the quarterly meetings. During a joint interview on 10/10/23 at 3:48 PM, the DON stated the resident (R#1) had dementia and a history of alcoholism; he was not aware of his aggressive behaviors. The Administrator stated that the resident had been aggressive during some unwitnessed episodes. R#1 was moved to another location hoping to control his behaviors. R#1 wants to help other residents. We have tried to transfer the resident to another facility without success at this time. The DON stated the CP should capture episodes of falls and episodes for aggression especially if they are repeating. The DON stated: I do not know why the CP was not routinely updated after every episode of aggression for R#1 against other residents, but it will be corrected. The Administrator stated a new intervention put in place for R#1 was the 72 hour monitoring after the third episode of aggression (09/02/23). The Administrator stated R#1's aggression was not captured in the CP because there was no injury to any resident; and the allegation was inconclusive. The Administrator stated, after the third episode of aggression interventions included: monitoring; and continuance of past interventions, separation and in-service on abuse/neglect, and explore a transfer of R#1 to another facility. The Administrator stated that R#1's CP was not updated to reflect the 72 monitoring. Regarding the fourth episode of aggression R#1 was moved to another hall in the secured unit. The Administrator stated the new intervention of moving R#1 to another hall was not captured in the CP. The DON stated the expected process for updating the CP included; any changes were to be captured in the care planned at time of the incident or at time of the new intervention and no later than the quarterly CP meeting. Record review of facility's Care Plan policy dated revised March 2023 read: .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 7 of 9 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 676481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive Port Lavaca, TX 77979 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. **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 acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 22 residents (R#8) reviewed for drug administration in that: Had this surveyor not intervened, CMA O would have administered R#8 her senna [a medication used to treat constipation] almost 12 hours before its scheduled timeframe. This deficient practice could affect residents who receive medication and place them at risk for not receiving a therapeutic effect. The findings were: Record review of R#8'S face sheet, dated 10/11/23, revealed R#8 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery [buildup of fats in the arteries that supply blood to the heart muscle] without angina pectoris [chest pain], contact with and (suspected) exposure to COVID-19, ganglion [a noncancerous lump], other site, and muscle wasting and atrophy [shrinking of muscle or nerve tissue], not elsewhere classified, multiple sites. Record review of R#8'S annual MDS, dated [DATE], revealed R#8 had a BIMS score of 12, signifying moderate cognitive impairment. Record review of R#8's physician orders obtained, 10/11/23, revealed the following orders: - Senna Oral Tablet 8.6 MG (Sennosides) Give 2 tablet, by mouth at bedtime for CONSTIPATION hold for loose stools/give 2 tablets to equal 17.2 mg. The start date of this medication was 10/3/23. Record review of R#8's October 2023 MAR and TAR, obtained 10/11/23, revealed R#8's Senna was scheduled to be given at 20:00 [8:00 p.m.] Observation, interview, and record review on 10/11/23 at 7:57 a.m. revealed CMA O began to prepare R#8's Senna. CMA O used a paper copy of R#8's MAR to prepare the medication. CMA O placed R#8's Senna into a plastic medication cup. On 10/11/23 at 8:10 a.m., CMA O poured water from the medication cart's water pitcher into a plastic cup, obtained a pair of gloves, and locked the medication cart. As CMA O was about to enter R#8's room, this surveyor intervened and asked CMA O if she was now going to give R#8 the medications she just prepared. CMA O stated, yes. This surveyor then asked CMA O to review R#8's October 2023 MAR and confirmed R#8's Senna was meant to be administered at 8:00 p.m. CMA O stated she was nervous and today was the first time she used a paper MAR. During an interview on 10/11/23 at 8:37 a.m., CMA O when asked what training did she have to ensure the right resident was given the right medication, CMA O stated, we have just the MARS that go off of. [sic]. CMA O stated the rights of medication administration include the right resident, right dose, right documentation, right route, and right time. When asked why it was important to ensure the right resident was given the right medication, CMA O stated, Because if it's the wrong person, you could harm them if they don't need it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 8 of 9 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 676481 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lavaca Bay Nursing and Rehabilitation Center 118 Trinity Shores Drive Port Lavaca, TX 77979 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 During an interview on 10/11/23 at 4:10 p.m., the DON stated, we have the [medication administration] competency that's done upon hire and we do it annually as a refresher and we also do it as needed. Corporate will come in and they'll do an observation and they'll make recommendation. It's a lot of [as needed] from time to time. The DON stated the facility's consulting pharmacist will also visit to do cart audits and medication administration observations. The DON stated the facility also conducted random medication cart checks weekly and these audits included checking if medication was given at the right time. When asked what sort of negative effects could occur to the resident if a medication was given at the wrong time, the DON stated, Depending on the medication, itself, it can have an effect where it's running into another medication that it shouldn't be given near and if you're not going an appropriate amount of time you can give something too close together. You can get sedations, you can get all sorts of outcomes by not following when the medication is supposed to be given. Record review of a facility policy titled, Administering Medications, dated April 2019, revealed the following: Medications are administered in accordance with the prescriber orders, including any required time frame . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676481 If continuation sheet Page 9 of 9