The Belmont At Twin Creeks

During an interview on 05/30/2026 at 2:11 p.m., the Administrator said she called the hospice agency to ask the hospice aide if she was the one who took off Resident #3's CPAP mask.

She said the hospice aide admitted that she was the one who took off the mask.

She said the agency would in-service the hospice aide.

She said the BiPAP and CPAP masks should be bagged to prevent any probable infections.

She said they were currently correcting the same non-compliance from a visit dated 04/21/2026.

Record review of the facility's policy Oxygen Concentrator P & P Committee implemented November 11, 2025 reflected Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators .

Policy Explanation and Compliance Guidelines . 4.

Use of the Concentrator . l.

Keep delivery devices covered in plastic bag when not in use.

676237 05/30/2026

The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013

05/29/2026 at 1:11 p.m., LVN C said she did not know that Resident #5 had medications inside his

result in overdosing.

She said she would go to the resident's room and check if the medications were

[AGE] year-old female who was admitted to the facility on [DATE].

The resident was diagnosed with chronic obstructive pulmonary disease and dementia (a condition characterized by loss of memory and ability to reason).

Record review of Resident #6's Quarterly MDS Assessment, dated 04/26/2026, reflected the resident had a moderate cognitive impairment (resident may need additional support and monitoring) with a BIMS score of 11.

The Quarterly MDS Assessment indicated the resident had chronic obstructive pulmonary disease and dementia.

Record review of Resident #6's Comprehensive Care Plan, dated 04/30/2026, reflected the resident had altered respiratory status and one of the interventions was to administer medications as ordered.

Record review of Resident #6's Physician Order, dated 04/09/2026, reflected Flonase Allergy Relief Nasal Suspension (Fluticasone Propionate (Nasal)) 1 spray in each nostril two times a day for Allergy.

Record review on 05/29/2026 of Resident #6's Assessment Notes reflected the resident did not have an assessment for self-administration of medications.During an observation and interview on 05/29/2026 at 7:36 a.m., Resident #6 was in her bed, awake. It was observed that she had a nasal spray on top of her side table.

The resident said the nasal spray had been in her table since the previous day.

During an interview on 05/29/2026 at 1:29 p.m., LVN B said she did not know that Resident #6 has a nasal spray inside her room.

She said the medication should not be inside the room because the resident might be confused and use it more than what was required.

She said, maybe, her daughter brought it.

During an interview on 05/29/2026 at 4:11 p.m., ADON A said barrier creams were a form of topical medications because they were used to prevent skin breakdown.

She said it should be stored where the residents could not access them.

She said confused residents could use the cream in their eyes.

She said residents that wandered around the facility and could go inside the room and get hold of the zinc oxide and use them also inappropriately.

She said medications inside the rooms could cause overdose because the staff would not know how many times the residents were administering the medications.

She said, what if the staff already administered the medication and then the resident would administer it again.

She said that would be dangerous.

She said she would coordinate with the DON about the issue and would go room to room to see if there were medications inside the residents' rooms.

During an interview on 05/30/2026 at 1:41 p.m., the DON said medications should not be inside the rooms of the residents because it could cause probable harm such as overmedication, undermedication, or allergic reactions.

She said the residents should have an assessment for self-medication to determine if they were able to administer medications by themselves.

She said the same rationale applied to the zinc oxides.

She said confused residents might use the creams inappropriately.

She said she would continually remind the staff not to leave the zinc oxide within reach of any residents and to scan the room of the residents for any medications.

During an interview on 05/30/2026 at 2:11 p.m., the Administrator said zinc oxides should not be accessible to the residents because they might accidentally consume them or put them in their eyes.

She said no medications should be inside the rooms of the residents because they might use them more than what was required.

She said they were currently correcting the same non-compliance from a visit dated 04/21/2026.

Record review of the facility's policy Medication Storage P & P Committee implemented December 01, 2025 reflected Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms .

Policy Explanation and Compliance Guidelines . 1.

General Guidelines . a.

All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) . b.

Only authorized personnel will have access to the keys to locked compartments.