Lone Star Ranch Rehabilitaion And Healthcare Cente

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

denied remembering any incident or altercation with any other residents. She denied experiencing any abuse by staff or residents. She was pleasantly confused. Record review of the facility's Abuse Prohibition Policy, revised 10/2022, revealed Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lone Star Ranch Rehabilitaion and Healthcare Cente

316 General Cavazos Blvd Kingsville, TX 78363

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 ensure all drugs and biologicals were stored in locked compartments for 1 of 4 treatment and medication carts (main treatment cart) reviewed for labeling and storage. The facility failed to ensure the main treatment cart belonging to RN-A was locked and secured. This failure could place the residents at risk of gaining access to unlocked medical supplies and medications which were not prescribed to them and could cause them harm.The findings included: Observation on 12/29/2025 at 8:19 AM revealed an unlocked treatment cart belonging to RN-A parked in the A Hall with no nurses or other staff around it. RN-A was in a room with a resident. There were residents noted to be ambulating in and down the halls. The main treatment cart lock was popped out, and all drawers were able to be opened and accessed. The main treatment cart was full of treatment supplies and treatment medications, to include scissors, needles, multiple containers of liquids, as well as a medication cup filled with a thick, white substance with a wooden spoon in it. Attempted to interview RN-A multiple times on 12/29/2025. She was performing treatments on residents at time the unlocked treatment cart was identified. RN-A left work early, as it was not her normal day or hours to work. Attempted to call RN-A multiple times on 12/29/2025 (called at 12:55 PM, texted at 12:56 PM, called at 5:01 PM) with no returned call or text from RN-A. In an interview on 12/29/2025 at 10:22 AM, the DON stated it was RN-A who worked on the main treatment cart today and did the resident treatments, and it was RN-A who left the main treatment cart unlocked. The DON stated all treatment carts and medication carts were to be locked for Resident safety if the nurse's step away from them. She stated if the carts were left unlocked residents could have gotten a hold of medications or supplies which could have caused them harm. She stated the last in-service for the nurses regarding medication carts was in November of 2024, so she went ahead and started an in-service today. In an interview on 12/29/2025 at 1:11 PM, the Administrator stated treatment and medication carts were supposed to be locked when not in use, and the nurses were responsible for their own medication and treatment carts. The cart was the responsibility of the nurse that was in control of

it for that shift. He stated this was done for the residents' safety so they did not have access to medications or supplies which could harm them. The Administrator stated the DON had already started an in-service regarding this. Record review of the facility's Medication Storage Policy, dated 06/24/2025, revealed 1.

Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended.

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